HospitalInspections.org

Based on observation, interview, and record review, the facility failed to ensure:

1. The document titled, "An Important Message From Medicare (IMM) About Your Rights," was provided to three sampled patients (Patients 1, 7 and 24), signed and dated two days after admission and two days prior to discharge (A 117);

2. A written response to a complainant's grievance was completed, for five of six sampled patients' grievances reviewed (Patients 33, 34, 35, 36, and 37) (A 123);

3. A review of Advance Directives (AD - a written document of a person's wishes regarding medical treatment should a person become unable to communicate them to the physician) were completed, for five sampled patients (Patients 8, 3, 4, 23, and 24) (A 132);

4. For one patient (Patient 10), a family member was notified in a timely manner of the patient's admission and health status after the patient authorized a release of information (A 133);

5. Sufficient numbers of qualified, trained, and experienced staff to safely implement the restraint process was provided (A 145) (A 194);

6. The physician's telephone order for mechanical restraints (any object or device attached or adjacent to an individual's body which cannot be removed easily by the patient and would limit the individual's movement) for one patient (Patient 11) was cosigned and validated by the physician (A 168);

7. For one sampled patient (Patient 30), the medications used as chemical restraints were not ordered on as needed basis (A 169);

8. For five sampled patients (Patients 30, 1, 4, 15, and 23), the patients' condition was monitored when restraints were implemented (A 175);

9. For five sampled patients (Patients 30, 1, 4, 15, and 23), the patients were seen face-to-face within one hour after restraints were applied (A 178);

10. For five sampled patients (Patients 30, 1, 4, 15, and 23), the patients' response to the use of restraints and the rationale for continued use of restraint were documented on the patients' record (A 188);

11. The performance improvement activities included indicators to track the performance of staff applying MAB (Management of Assaultive Behavior) techniques in physical restraint take downs and the transfer of patients who were physically restrained on the floor (A 283);

12. There were adequate numbers of staff in accordance with patient acuities (a measurement of the intensity of nursing care needed by patients) for multiple dates, shifts, and nursing units (A 392);

13. Complete assessments and reassessments were conducted by the nursing staff, for three sampled patients (Patients 2 and 10) (A 395);

14. Patient 3's documentation of safety observations were accurate (A 395);

15. The documentation of safety observations were signed by the Registered Nurse (RN), for 20 sampled patients (Patients 1, 2, 3, 4, 9, 10, 12, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 27, and 28) (A 395);

16. The records for Activities of Daily Living (ADLs) were completed, for eight sampled patients (Patients 15, 16, 17, 18, 19, 20, 23, and 24) (A 395);

17. Adequate supervision and evaluation of staff in MAB (Management of Assaultive Behavior) techniques, physical restraint takedowns, and the transfer of patients who were physically restrained on the floor were provided (A 398);

18. The laboratory tests were completed as ordered by the physician, for one sampled patient (Patient 26) (A 398);

19. For Patients 25, 28, 3, 4, 8, 9, 10, 14, 18, 21, and 23, the medications were administered as ordered by the physician (A 405);

20. Assessment and reassessment were conducted when medications on as needed (prn) basis were administered to Patients 28, 30, 6, 7, 8, 10, 13 and 14 (A 405);

21. For Patient 26, the physician was notified when the patient refused to take Synthroid (thyroid medication) and Depakote (medication used to treat seizure)(A 405);

The cumulative effect of these systemic problems resulted in failure to ensure the governing body was effective in carrying out its responsibilities for the conduct of the facility.

On September 28, 2021, at 4:20 p.m., the Chief Executive Officer (CEO), and the Director of Quality and Risk Management (DQRM), were notified of the determination of an immediate jeopardy situation to the health and safety of patients related to unsafe practices used during the restraint process.

The facility developed a plan of correction, and the CEO and the DQRM were notified the facility's plan of action was accepted on September 28, 2021, at 6:05 p.m.

On September 29, 2021, at 9:45 a.m., implementation of the plan of action was verified onsite and the CEO and the DQRM were notified that the immediate jeopardy situation was abated. (Refer to A 115).

The plan of action indicated:

1. All patient care staff will be retrained in safe patient handling to include properly transferring patients from the ground to the restraint gurney or restraint bed.

2. Physical holds, proper restraint of patients, inappropriate to use knees to hold patients down: All patient care staff will be retrained on not using knees to physically hold a patient down.

3. Proper restraint of a combative patient, hands-on education of and training of all employees on the proper restraint of a combative patient: A member of the leadership team will be assigned to conduct a debriefing with staff involved in a take down.



39503

Based on observation, interview, and record review, the facility failed to ensure:

1. The document titled, "An Important Message From Medicare (IMM) About Your Rights," was provided to three sampled patients (Patients 1, 7, and 24), signed and dated two days after admission and two days prior to discharge (A 117);

2. A written response to a complainant's grievance was completed, for five of six sampled patients' grievances reviewed (Patients 33, 34, 35, 36, and 37) (A 123);

3. A review of Advance Directives (AD, a written document of a person's wishes regarding medical treatment should the person becomes unable to communicate them to the physician) was completed, for five sampled patients (Patients 8, 3, 4, 23, and 24) (A 132);

4. A family member was notified in a timely manner of the patient's admission and health status after the patient authorized a release of information, for one patient (Patient 10) (A 133);

5. There were sufficient numbers of qualified, trained, and experienced staff to safely implement the restraint process (A 145) (A 194);

6. The physician's telephone order for mechanical restraints (any object or device attached or adjacent to an individual's body which cannot be removed easily by the patient and would limit the individual's movement) was cosigned and validated by the physician, for one patient (Patient 11) (A 168);

7. The medications used as chemical restraints were not ordered on as needed basis, for one sampled patient (Patient 30) (A 169);

8. The patients' conditions were monitored when restraints were implemented, for five sampled patients (Patients 30, 1, 4, 15, and 23) (A 175);

9. The patients were seen face-to-face within one hour after restraints were applied, for five sampled patients (Patients 30, 1, 4, 15, and 23) (A 178); and

10. The patients' response to the use of restraints and the rationale for continued use of restraint were documented on the patients' record, for five sampled patients (Patients 30, 1, 4, 15, and 23) (A 188);

The cumulative effect of these systemic problems resulted in the facility's failure to ensure the rights of patients at the facility were promoted and protected.



22384

On September 28, 2021, at 4:20 p.m., the Chief Executive Officer (CEO), and the Director of Quality and Risk Management (DQRM), were notified of the determination of an immediate jeopardy situation to the health and safety of patients related to unsafe practices used during the restraint process.

The facility developed a plan of correction, and the CEO and the DQRM were notified the facility's plan of action was accepted on September 28, 2021, at 6:05 p.m.

On September 29, 2021, at 9:45 a.m., implementation of the plan of action was verified onsite and the CEO and the DQRM were notified that the immediate jeopardy situation was abated. (Refer to A 115).

The plan of action indicated:

1. All patient care staff will be retrained in safe patient handling to include properly transferring patients from the ground to the restraint gurney or restraint bed.

2. Physical holds, proper restraint of patients, inappropriate to use knees to hold patients down: All patient care staff will be retrained on not using knees to physically hold a patient down.

3. Proper restraint of a combative patient, hands-on education of and training of all employees on the proper restraint of a combative patient: A member of the leadership team will be assigned to conduct a debriefing with staff involved in a take down.

The plan of action also indicated all seclusion and restraint events will be analyzed and deficient practices will be reported to thre Quality Council monthly, Medical Executive Committee quarterly, and Governing Board.

Based on interview and record review, the facility failed to ensure the document titled, "An Important Message From Medicare (IMM) About Your Rights," was provided to three sampled patients (Patients 1, 7, and 24), signed and dated two days after admission and two days prior to discharge. This failure had the potential to result in the patients to not be aware of their right to appeal their discharge from the facility.

Findings:

1. A review of Patient 1's record was conducted on September 27, 2021. Patient 1 was admitted to the facility on September 20, 2021, with a diagnosis of schizoaffective disorder (a mental disorder affecting thoughts, mood and behavior).

There was no indication Patient 1 received and acknowledged the receipt of the IMM document as an IMM was in Patient 1's record prior to discharge but the document was neither dated nor signed prior to the patients discharge on September 27, 2021.

2. A review of Patient 7's record was conducted on October 1, 2021. Patient 7 was admitted to the facility on September 24, 2021, with a diagnosis of schizophrenia (a mental disorder affecting thoughts and behavior). Patient 7 was still in the facility receiving treatment.

There was no indication Patient 7 received and acknowledged the receipt of the IMM document as an IMM was placed in Patient 7's record after admission but was not dated nor signed.

3. A review of Patient 24's record was conducted on October 1, 2021. Patient 24 was admitted to the facility on September 9, 2021, with a diagnosis of schizophrenia.

There was no indication Patient 24 received and acknowledged the receipt of the IMM document as an IMM was placed in Patient 24's record after admission but was not dated nor signed.

An interview was conducted with the Director of Admissions and Business Development (DABD) on September 29, 2021, at 4 p.m. The DABD stated the nurses were supposed to have the IMM letter signed and completed shortly after admission and prior to the patient's discharge.

A review of the facility policy and procedure titled, "Important Message from Medicare and Tri-Care (Reviewed: 10/2020)," was conducted. The purpose indicated, "...To provide guidelines to ensure that Medicare/Tricare patients are aware of the steps required to appeal discharge from the facility..."

The method indicated, "...Upon admission the Admissions staff explain the "Important Message from Medicare or Tricare" to the patient. The patient signs the form confirming acknowledgment of receipt...The form is placed in the discharge section of the chart...Social Work staff review the form with the patient and have the patient again sign and acknowledge the form 48 hours to 4 (four) hours before discharge."

Based on interview and record review, the facility failed to ensure a written response to a complainant's grievance was completed, for five of six sampled patients' grievances reviewed (Patients 33, 34, 35, 36, and 37).

This failure resulted in the complainants not being informed in writing of the resolution to their grievances to include the date of resolution.

Findings:

During a concurrent interview and record review on October 4, 2021, at 10:05 a.m., conducted with the Chief Executive Officer (CEO), the facility's grievance log was reviewed. The grievance log indicated the following:

- On March 25, 2021, Patient 33 filed a grievance related to physical abuse. The grievance had a resolution date of March 30, 2021.

There was no documented evidence a written response to or resolution of Patient 33's grievance was sent to the patient;

- On July 29, 2021, Patient 34 filed a grievance regarding discharge process.
The grievance had a resolution date of August 4, 2021.

There was no documented evidence a written response to or resolution of Patient 34's grievance was sent to the patient;

- On October 8, 2020, Patient 35 filed a grievance related to abuse. The grievance had a resolution date of October 12, 2020.

There was no documented evidence a written response to or resolution of Patient 35's grievance was sent to the patient;

- On October 15, 2020, Patient 36 filed a grievance related to abuse. The grievance had a resolution date of October 18, 2020.

There was no documented evidence a written response to or resolution of Patient 36's grievance was sent to the patient; and,

- On October 19, 2020, Patient 37's family representative (RP) filed a grievance regarding physician's communication. The grievance had a resolution date of October 21, 2020.

There was no documented evidence a written response to or resolution of Patient 37's RP's grievance was sent to the patient's RP.

The CEO stated when a grievance was received, a letter of acknowledgement would be sent to the complainant within seven days of receiving the grievance, and a copy of the letter sent would be filed on the grievance log.

The CEO stated when the filed grievance was resolved within seven days, the resolution would be included in the letter sent to the complainant. The CEO stated when the grievance could not be resolved within seven days of receiving the grievance, a follow-up written letter would be sent to the complainant informing the status of the grievance and a time extension, if needed.

The CEO stated there was no documented evidence a written response to or resolution of the grievances was sent to Patients 33, 34, 35, and 36, and to Patient 37's RP when they filed a grievance to the facility.

During a review of the facility's policy and procedure (P&P) titled, "Grievance Procedure - Patients," last revised in March 2019, the P&P indicated, "...The Risk Manager will attempt to respond in writing to all grievances within seven (7) calendar days of receipt of the grievance. Due to complexity of the grievance, if a written response cannot be made within seven (7) calendar days, the Patient Advocate will inform the patient or his/her representative that the hospital is still working to resolve the grievance and that a written response will be made within thirty (30) calendar days of receipt of the grievance...

The grievance and problem resolution/follow up should be documented. This documentation should include:

- Date complaint received
- Name of the hospital contact person
- Name of person voicing a grievance/how to contact
- Patient name
- Nature of complaint
- Pertinent investigation information
- Resolution of grievance/follow up
- Signature of Patient Advocate
- Date complaint resolved...

The patient shall be given a copy of the complaint, as requested, and final decision and a copy shall be filed in the complaint/grievance log..."

Based on interview and record review, the facility failed to ensure a review of Advance Directives (AD) were completed, for five sampled patients (Patients 8, 3, 4, 23, and 24).

This failure had the potential to deny patients their rights to formulate an AD.

Findings:

1. On September 28, 2021, Patient 8's record was reviewed. Patient 8 was admitted to the facility on April 17, 2021, with diagnosis of major depressive disorder (a mood disorder).

During a concurrent interview and record review, on September 29, 2021, at 11 a.m., conducted with the Director of Admissions and Business Development (DABD), Patient 8's "Organ Donation/Advanced Directives" acknowledgement form, dated April 17, 2021, was reviewed. The form indicated Patient 8 did not have an AD. The yes or no answer that indicated whether Patient 8 was offered written information on how to formulate an AD was not marked. The DABD stated if a patient did not have an AD, facility staff should review with the patient if he/she would like information on how to formulate an AD.

The DABD stated there was no documentation indicating information on formulating an AD was reviewed by facility staff with Patient 8.



22384

2. A review of Patient 3's record was conducted on September 29, 2021. Patient 3 was admitted to the facility on September 21, 2021, with a diagnosis of bipolar disorder (a mood disorder).

Further review of Patient 3's record reflected an acknowledgement form titled, "Organ Donation /Advanced Directives." The acknowledgment form was not completed and did not indicate if Patient 3 would like further information on living wills and advanced directives. The bottom of the document, dated September 21, 2021, at 1:22 p.m., indicated Patient 3 verbally refused to sign. Further review of the record failed to show follow up with Patient 3 regarding the AD.

An interview was conducted with the DABD, on September 29, 2021, at 10:45 a.m., who, after reviewing Patient 3's record, stated the staff should follow up with patients twice when they initially refused to sign the acknowledgement form to determine if the patient would like further information on living wills and advance directives. The DABD further stated there was no follow up with Patient 3 reflected in the record.

3. A review of Patient 4's record was conducted. Patient 4 was admitted to the facility on September 1, 2021, with a diagnosis of schizophrenia (a mental disorder which affect thoughts and behavior).

Further review of Patient 4's record reflected an acknowledgement form titled, "Organ Donation /Advanced Directives." The acknowledgment form was not completed and did not indicate if Patient 4 would like further information on living wills and advanced directives. The bottom of the document, dated September 1, 2021, at 3:30 p.m., indicated, "...pt (Patient 4) too disorganized..." Further review of the record failed to show follow up with Patient 4 regarding the AD.

An interview was conducted with the DABD, on September 29, 2021, at 10:50 a.m., who, after reviewing Patient 4's record, stated the staff should follow up with patients twice when they initially are not able to sign the acknowledgement form to determine if the patient would like further information on living wills and advance directives. The DABD further stated there was no follow up with Patient 4 reflected in the record.



43559

4. On October 4, 2021, Patient 23's record was reviewed. Patient 23 was admitted to the facility on September 7, 2021, with the diagnosis of schizophrenia.

During a concurrent interview and record review, on October 4, 2021, at 8:00 a.m., conducted with the Director of Nursing (DON), Patient 23's "Organ Donation/Advanced Directives" acknowledgement form, dated September 7, 2021, was reviewed. The form indicated Patient 23 refused to sign the document. The yes or no answer that indicated whether Patient 23 was offered written information on how to formulate an AD was not marked.

The DON stated if a patient does not have an AD, facility staff should review with the patient if he/she would like information on how to formulate an AD. The DON stated there was no documentation that indicated information on formulating an AD was reviewed with Patient 23 by facility staff.

5. On October 4, 2021, Patient 24's record was reviewed. Patient 24 was admitted to the facility on September 9, 2021, with a diagnosis of schizophrenia.

During a concurrent interview and record review, on October 4, 2021, at 8:30 a.m., conducted with the DON, Patient 24's "Organ Donation/Advanced Directives" acknowledgement form, dated September 9, 2021, was reviewed. The form reflected Patient 24 refused to sign the document and indicated, "I can't see." The yes or no answer that indicated whether Patient 24 was offered written information on how to formulate an AD was not marked.

The DON stated if a patient did not have an AD, facility staff should review with the patient if he/she would like information on how to formulate an AD. The DON stated there was no documentation that indicated information on formulating an AD was reviewed with Patient 24 by facility staff.

During a review of the facility's policy and procedure (P&P) titled, "Advance Directives," with a revised date of August 2019, the P&P indicated, "...At the time of admission, the Admissions/Nursing staff will provide to the patient written information including...An Advance Directive Acknowledgement Form which describes the hospital's responsibility to inform the patient of his/her right to formulate advance medical directives...The patient will be asked whether he or she has an Advanced Directive...If, at the time of admission, the patient lacks the mental capacity to read and understand the written materials on Advanced Directives, or the Advanced Directive Acknowledgement Form...Nursing personnel must provide these materials to the patient as soon as the patient regains capacity..."

Based on interview and record review, the facility failed to ensure a family member was notified in a timely manner of the patient's admission and health status after the patient authorized a release of information (ROI), for one patient (Patient 10).

This failure resulted in a delay of notifying Patient 10's family member and had the potential to deny Patient 10's rights.

Findings:

On September 30, 2021, Patient 10's record was reviewed. Patient 10 was admitted to the facility on April 29, 2021, with diagnoses that included bipolar disorder.

On the "Initial Psychiatric Evaluation," dated April 30, 2021, at 9 a.m., the physician indicated, "...I have requested the social worker to attempt to reach out to the patient's (family member) to collaborate care and get more information..."

Patient 10's "Authorization to Disclose Healthcare Information," dated April 30, 2021, at 3:04 p.m., indicated Patient 10 authorized all healthcare information to be released to her family member.

Patient 10's "Social Services Documentation of Patient Progress" notes, dated April 30, 2021, at 3:57 p.m., indicated, "...Patient (Patient 10) reported she lives in (city name) w/ (with) (Patient 10's family member)...SW (social worker) was able to look in patient's chart to find a number for (family member)...SW got ROI and will f/u (follow-up) with (family member)..." Further review of the notes indicated an effort to reach Patient 10's family member was not attempted until May 5, 2021, at 1:43 p.m. (five days later).

During an interview on September 30, 2021, at 11:30 a.m., conducted with the Director of Clinical Services (DCC), the DCC stated once an ROI was signed by the patient authorizing the facility to release information to an individual, the individual should be contacted that same day or within 24 hours.

During a review of the facility's policy and procedure (P&P) titled, "Authorization for Release of Information", with a reviewed date of July 2020, the P&P indicated, "...The Medical Records Department/Social Worker/Case Manager shall secure separate signed authorization from the patient...For authorization to contact family and/or friends...The patient may...sign an authorization to contact the family and/or friends from specifying who may be contacted on their behalf..."

Based on observation, interview, and record review, the facility failed to ensure there were sufficient numbers of qualified, trained, and experienced staff to safely implement the restraint process.

This failure potentially resulted in four patients (Patients 12, 9, 1, and 3) being subjected to both a physical and emotionally abusive environment in violation of the patients' rights.

Findings:

1. During an observation on September 28, 2021, at 3:30 p.m., in the facility lobby, Patient 12 was observed by two members of the state agency survey team during a code white (indicating a pending emergency with a violent or combative patient) to be taken down to the ground, face down, and physically restrained by multiple staff members at each limb. Patient 12's right leg was observed to be physically restrained and held to the ground by Registered Nurse (RN) 3's left knee on the patient's right calf.

During an interview on September 28, 2021, at 3:40 p.m., conducted with RN 3, RN 3 stated he used his knee to physically restrain Patient 12's right leg after the patient was taken down to the ground. RN 3 stated this was a mistake. RN 3 stated knees should not be used to physically restrain patients. RN 3 stated only hands should be used.

During an interview on September 29, 2021, at 10 a.m., conducted with the Director of Nursing (DON), the DON stated knees should never be used to physically restrain or contain patients. The DON stated only hands should be used when physical restraints were needed.

Patient 12's record was reviewed on October 1, 2021. Patient 12 was admitted to the facility on September 21, 2021, with diagnoses that included schizophrenia (a mental disorder) and autism (a developmental disability which aould cause significant social, communication, and behavioral challenges).

2. During an interview on September 28, 2021, at 1 p.m., conducted with Registered Nurse (RN) 1, RN 1 stated when a patient was physically restrained on the floor, the correct way to transfer was by either escorting the patient onto his feet holding shoulder/arms or by using the gurney and flipping the patient over face up.

RN 1 stated he has seen patients at the facility being transferred face down by being lifted and carried by their limbs.

RN 1 stated it is very unsafe to transfer patients in this manner since it can cause hyperextension (the forceful extension of a limb or joint beyond its normal limits) and pain to the patient.

During an interview on September 28, 2021, at 4:20 p.m., conducted with Social Worker (SW) 1, SW 1 stated she was a witness to Patient 9's takedown to the ground and transfer from the floor to the restraint/seclusion room on September 27, 2021. SW 1 stated she witnessed Patient 9 transferred from the ground by four staff, one at each limb. SW 1 stated each staff member grabbed one of Patient 9's limbs, lifted the patient into the air, while the patient was face down, and carried him this way down the hallway, past the nurse's station, to the restraint/seclusion room. SW 1 further stated she verbalized to the staff they needed to stop because they were going to break his spine, but the staff ignored her.

On September 29, 2021, Patient 9's record was reviewed. Patient 9 was admitted to the facility on September 21, 2021, with the diagnosis of schizophrenia.

Patient 9's "Seclusion/Restraint Packet," dated September 27, 2021, at 3 p.m., indicated the physician ordered mechanical and chemical restraints for Patient 9.

During an interview on October 1, 2021, at 9:10 a.m., with the Director of Nursing (DON), the DON stated there was no specific education or hands-on training provided to staff regarding the transfer patients who are physically restrained on the floor.



22384

3. A review of Patient 1's record was conducted. Patient 1 was voluntarily admitted to the facility on September 20, 2021, with a diagnosis of schizoaffective disorder, bipolar type (a mental disorder characterized by abnormal thought processes, an unstable mood, and episodes of mood swings).

An interview was conducted with RN 4, on September 27, 2021, at 3 p.m. RN 4 stated on September 23, 2021, around 3:30 p.m., a code white (indicating a pending emergency with a violent or combative patient) regarding Patient 1 was called. RN 4 further stated Patient 1 was cursing and threatening others.

During a concurrent observation and interview, on September 27, 2021, at 5 p.m. Patient 1 was observed seated in the facility's lobby. Patient 1 was alert, calm, his voice clear, as he stated he was discharged and waiting for transportation to take him home. Patient 1 stated, "I felt blows when I was being taken down, they put their knees on my neck. I said I couldn't breathe. They put me on a 72 hour hold (an involuntary hold when a patient was determined to be a danger to himself or others)."

Patient 1 further stated, "The social worker was very upset to see what happened to me. I was chicken winged (when a patient was positioned prone in the chicken wing position, with the shoulders in an abnormal posterior angulation and the hands behind the back) and they (facility staff) were standing on the back of my feet. I have bumps on my head and my ribs hurt on my left side."

An interview was conducted with SW 1, on September 27, 2021, at 5:20 p.m. SW 1 stated she spoke with Patient 1 on September 24, 2021, and he told her he was "triggered by the floor staff (on September 23, 2021) and pushed the charge nurse and he knew it was his fault."

SW 1 stated she touched Patient 1's head and could feel bumps on top of his head. SW 1 stated Patient 1 told her the facility staff punched him on the back of his head and another staff twisted his arm behind his back and was kneeling on his back. SW 1 stated she observed red marks on his back and on the left side of his neck.

An interview was conducted with Behavioral Health Associate (BHA) 1 on September 28, 2021, at 11 a.m. BHA 1 stated he was the target of Patient 1, when the patient became agitated on September 23, 2021. BHA 1 stated he saw a staff member grab Patient 1's arm and put him to the ground.

BHA 1 further stated he had worked at the facility for 9 months and before being hired, he had no prior training in mental health.

BHA 1 stated he had MAB (Management of Assaultive Behavior) training but did not have ongoing training on how to physically restrain a patient or how to place restraints on a patient.

BHA 1 stated he did not have an opportunity to practice hands-on techniques for restraining of patients. BHA 1 stated he would watch other staff to learn the takedown/restraint process.

BHA 1 stated he had put his knees on patient's arms or legs to restrain them and he had seen patients being picked up by their arms and legs while on their stomach.

An interview was conducted with the DON, on September 28, 2021, at 2 p.m. The DON stated during the process of restraining a patient, only a person's hands should be used to restrain a patient. The DON stated knees should never be placed on the patient's neck, back, or anywhere on the patient.

4. A review of Patient 3's record was conducted. Patient 3 was admitted to the facility on September 21, 2021, with a diagnosis of bipolar disorder (a mood disorder).

An interview was conducted with the Marriage and Family Therapist (MFT) on September 27, 2021, at 12 p.m. The MFT stated she was present during a restraint episode involving Patient 3. She further stated during the restraint episode, she observed BHA 2 placing his knee on Patient 3's neck and shoulder area.

An interview was conducted with Behavioral Health Associate (BHA) 2 on September 27, 2021, at 1:30 p.m. BHA 2 stated he was involved in a restraint episode involving Patient 3 when the patient swung at him and was using vulgar language.

BHA 2 said he was able to take the patient down to the floor. BHA 2 stated BHA 1 and RN 4 came into the room. BHA 2 stated they transferred the patient to the bed by holding her arms and legs while the patient was in a prone position.

BHA 2 stated this was the first time he "took down" a patient and no one had taught him how to do that. BHA 2 stated he was not involved in the staff debriefing process after Patient 3's restraint episode.

An interview was conducted with BHA 1 on September 28, 2021, at 11:00 a.m. BHA 1 stated he was involved with the restraint episode involving Patient 3 on September 23, 2021. BHA 1 stated he went to assist BHA 2 with Patient 3 as the patient was cursing and agitated.

BHA 1 stated he had worked at the facility for 9 months and before being hired, he had no prior training in mental health.

BHA 1 stated he had MAB (Management of Assaultive Behavior) training but did not have ongoing training in how to physically restrain a patient or how to place restraints on a patient.

BHA 1 stated he did not have an opportunity to practice hands-on techniques for restraining of patients. BHA 1 stated he would watch other staff to learn the takedown/restraint process.

BHA 1 stated he had put his knees on patient's arms or legs to restrain them and he had seen patients being picked up by their arms and legs while the patients were on their stomach.

BHA 1 stated he helped other staff transfer Patient 3 to the bed. BHA 1 stated he grabbed Patient 3's arm and leg while she was lying on her stomach and assisted the staff in transferring the patient on the bed while she remained in a face down position.

An interview was conducted with the DON, on September 28, 2021, at 2 p.m. The DON stated during the process of restraining a patient only a person's hands and body weight should be used to restrain a patient The DON stated knees or elbows should never be placed on the patient's neck, back, or anywhere on the patient. The DON stated during every restraint episode, a staff debriefing should be conducted to follow up on any problems encountered during the restraint process and all staff involved should be present at the debriefing. The DON stated the findings during the staff debriefing process would be used for education and training purposes.

An interview was conducted with the DON on September 29, 2021, at 9:20 a.m. The DON stated the BHAs were not utilizing the resources present in the facility to assist with patient transfers, such as using the backboards to safely transfer patients.

An interview was conducted with RN 1 on September 30, 2021, at 4 p.m., who stated prior to transferring a patient during a restraint episode, the patient must be rolled onto their back and placed onto a backboard or gurney to transfer the patient onto a bed. RN 1 further stated if a patient watransferred in a face down position the patient could hit his head on the floor.

A review of the facility's job description for a Behavioral Health Associate indicated, "...Purpose Statement...Responsible for providing personal care services to patients at the facility under the direction of clinical or nursing leadership...Recognize that patient safety is a top priority...Education/Experience/Skill Requirements...High school diploma or equivalent required...Six month or more experience working with the specific population of the facility preferred..."

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint of Patient," with a revised date of September 2019, the P&P indicated, "...To provide guidelines for the appropriate use of seclusion and/or restraint in clinically justified circumstances. To provide guidelines for patient monitoring and care in order to promote patient safety, protection, and to maintain the patient's rights and dignity. To ensure that restraint and/or seclusion procedures conform with all accrediting standards and State and Federal regulations and to guarantee all patients their human and civil rights. Hospital leadership strives to minimize the use of restraint and whenever possible to eliminate its use through staff training, thorough assessment, effective treatment planning, management of the environment, and ongoing performance improverment efforts...

It is the policy of (the facility) to limit the use of seclusion and/or restraint to emergencies in which there is an imminent risk of a patient physically harming himself/herself or others, including staff. Seclusion or restraint will only be employed after the use of less restrictive, non-physical measures, and have proven unuccessful in modifying the behavior for which the use of seclusion and/or restraint is considered. Seclusion and/or restraint shall be discontinued as soon as possible. The patient's rights, dignity, safety, and well being will be supported and maintained. Seclusion and/or restraint will not be used as a punitive measure or as a means of coercion, discipline, convenience or retaliation by staff...

The Registered Nurse will document behaviors which led to the need for the use of restraint in the Restraint/Seclusion Packet. Patients will be physically restrained in the supine positon, unless contraindicated and in accordance with MAB (Management of Assaultive Behavior Course), Approved MAB holds are considered a physical restraint...

Staff who witnessed the precipitating events and/or who were involved in the restraint process will participate in the staff team debriefing session. Staff debriefing is to be documented on the Staff Team Debriefing form...Staff Competency and Education...Employees must demonstrate competency in [MAB and Seclusion & Restraint] procedures...The focus of training is...containment techniques, including escort procedures..."

During a review of the facility's undated MAB educational booklet titled, "MAB M2 Clinical Containment Program," the booklet indicated, "...Any behavioral intervention must be consistent with the Patient's rights to be treated with dignity and to be free from abuse...The Response Team focuses on the prevention of un-needed pressures on the patient during the containment process..."

There was no documentated evidence on the booklet which indicated knees should be used on patients to physically restrain or contain.

Based on interview and record review, the facility failed to ensure the physician's telephone order for mechanical restraints (any object or device attached or adjacent to an individual's body which cannot be removed easily by the patient and would limit the individual's movement) was cosigned and validated by the physician, for one patient (Patient 11).

This failure had the potential to result in an inappropriate, unnecessary, and prolonged use of restraints.

Findings:

During a concurrent interview and record review on September 30, 2021, at 1:50 p.m., conducted with Registered Nurse (RN) 1, Patient 11's record was reviewed. Patient 11 was admitted to the facility on July 20, 2020, with a diagnosis of bipolar disorder (a mood disorder).

Patient 11's "Seclusion/Restraint Practitioner Order," indicated a registered nurse documented receiving a telephone order for four (4) point (both arms and both legs) mechanical restraints on July 25, 2020, at 6:25 a.m. The telephone order for 4-point restraint was not signed by the physician.

RN 1 stated there was no physician signature for the 4-point mechanical restraint telephone order on July 25, 2020. RN 1 stated telephone restraint orders should be signed within 24 hours.

Based on interview and record review, the facility failed to ensure the medications used as chemical restraints were not ordered on as needed (PRN) basis, for one sampled patient (Patient 30).

This failure had the potential to result in Patient 30 to have inappropriate, unnecessary, and prolonged use of restraints, and had the potential to violate the patient's rights.

Findings:

During an interview on October 1, 2021, at 11:36 a.m., conducted with Registered Nurse (RN) 2, RN 2 stated she administered the three medications (Haldol, Benadryl, and Ativan) via IM to Patient 30 on September 25, 2021, at 3:50 p.m.

RN 2 stated Patient 30 was agitated and had the PRN orders so she gave it to the patient. RN 2 stated she was aware when the three medications were given together by IM, it was considered a chemical restraint. RN 2 stated she was aware chemical restraints should not be written as PRN orders.

RN 2 stated she should have not given the PRN medications and she should have called the physician if Patient 30 needed to be on chemical restraint.

During a concurrent interview and record review, on October 1, 2021, at 12:15 p.m., conducted with the Director of Nursing (DON), Patient 30's record was reviewed. The "History and Physical" indicated Patient 30 was admitted to the facility on September 21, 2021, for psychiatric treatment.

Patient 30's "Physician's Order," dated September 21, 2021, at 5:24 p.m., indicated the following:

- Administer Haldol (medication used to treat mental and/or mood disorder) 10 milligram (mg) intramuscularly (IM, injection into the muscle) every two hours PRN for agitation or psychosis, not to exceed two doses in a day;

- Administer Benadryl (medication used for anxiety) 50 mg IM every two hours PRN for agitation or psychosis, not to exceed two doses in a day; and

- Administer Ativan (a sedative medication) 2 mg IM every two hours PRN for agitation or psychosis, not to exceed two doses in a day.

Patient 30's "Medication Administration Record," indicated the patient was administered Haldol 10 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM on the following dates and times:

- On September 23, 2021, at 10:08 p.m.;

- On September 25, 2021, at 1:22 a.m., and 3:50 p.m.;

- On September 26, 2021, at 4:30 a.m.; and

- On September 27, 2021, at 6:20 a.m.

Patient 30's "Progress Notes" indicated the following:

- "...9/26/21 (September 26, 2021) 0420 (4:20 a.m.)...pt (Patient 30) began to yell and bang room door...proceeded to offer 1:1 interaction, distraction methods and deescalation techniques. Pt. refused and proceeded to request PRN medication...PRN Haldol 10 mg IM and Ativan 2 mg IM administered on R (right) buttock...Benadryl 50 mg IM on L (left) buttock...;" and,

- "...9/27/21 (September 27, 2021) 0600 (6 a.m.) Pt. became aggressive and agitated towards other patients. He (Patient 30) started hitting the walls. Pt. was verbally redirected x 3 (three times) however he became more agitated. Pt. has an order for Haldol 10 mg, Ativan 2 mg and Benadryl 50 mg IM - PRN for agitation. Pt. willingly took the IM..."

The DON stated the combination of Haldol, Benadryl, and Ativan when administered to a patient via IM would be considered as chemical restraint. The orders for the three medications (Haldol, Benadryl, and Ativan) given IM should not be written as PRN orders.

The DON stated when a patient needed chemical restraint, the Registered Nurse (RN) should call the physician to obtain a one time order. The DON stated the RN should follow the policy and procedure (P&P) when administering chemical restraints to a patient.

During a review of the facility's P&P titled, "Seclusion and Restraint of Patient," last reviewed in September 2019, the P&P indicated, "...Restraint may only be ordered by a practitioner (Physician). Orders for restraint shall never be written as a standing order or on as needed basis (PRN)..."

Based on interview and record review, the facility failed to ensure the patients' conditions were monitored when restraints were implemented, for five sampled patients (Patients 30, 1, 4, 15, and 23).

This failure had the potential to result in inappropriate, unnecessary, and prolonged use of restraints, and had the potential to violate the patient's rights.

Findings:

1. During a concurrent interview and record review, on October 1, 2021, at 12:15 p.m., with the Director of Nursing (DON), Patient 30's record was reviewed. The "History and Physical" indicated Patient 30 was admitted to the facility on September 21, 2021, for psychiatric treatment.

Patient 30's "Physician's Order," dated September 21, 2021, at 5:24 p.m., indicated the following:

- Administer Haldol (medication used to treat mental and/or mood disorder) 10 milligram (mg) intramuscularly (IM, injection into the muscle) every two hours PRN for agitation or psychosis, not to exceed two doses in a day;

- Administer Benadryl (medication used for anxiety) 50 mg IM every two hours PRN for agitation or psychosis, not to exceed two doses in a day; and

- Administer Ativan (a sedative medication) 2 mg IM every two hours PRN for agitation or psychosis, not to exceed two doses in a day.

Patient 30's "Medication Administration Record," indicated the patient was administered Haldol 10 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM on the following dates and times:

- On September 23, 2021, at 10:08 p.m.;

- On September 25, 2021, at 1:22 a.m., and 3:50 p.m.;

- On September 26, 2021, at 4:30 a.m.; and

- On September 27, 2021, at 6:20 a.m.

Patient 30's "Progress Notes" indicated the following:

- "...9/26/21 (September 26, 2021) 0420 (4:20 a.m.)...pt (Patient 30) began to yell and bang room door...proceeded to offer 1:1 interaction, distraction methods and deescalation techniques. Pt. refused and proceeded to request PRN medication...PRN Haldol 10 mg IM and Ativan 2 mg IM administered on R (right) buttock...Benadryl 50 mg IM on L (left) buttock..."; and

- "...9/27/21 (September 27, 2021) 0600 (6 a.m.) Pt. became aggressive and agitated towards other patients. He (Patient 30) started hitting the walls. Pt. was verbally redirected x 3 (three times) however he became more agitated. Pt. has a order for Haldol 10 mg, Ativan 2 mg and Benadryl 50 mg IM - PRN for agitation. Pt. willingly took the IM..."

There was no documented evidence Patient 30's condition was monitored when the patient received the medications mentioned above.

The DON stated the combination of Haldol, Benadryl, and Ativan when administered to a patient by IM would be considered a chemical restraint. The DON stated when a restraint was applied on a patient, the patient's condition should be monitored.

The DON stated the monitoring of the patient on restraints should be documented on the restraint monitoring packet.

The DON stated there was no restraint monitoring packet completed when Patient 30 received chemical restraints on September 23, 25, 26, and 27, 2021. The DON stated Patient 30's condition was not monitored when the patient received chemical restraints on the dates mentioned above.

The DON stated the RN should follow the policy and procedure when administering chemical restraints to a patient.



22384

2. During a concurrent observation and interview on September 27, 2021, at 5 p.m., conducted with Patient 1, Patient 1 was observed seated in the facility's lobby. Patient 1 was alert, calm, his voice clear as he stated he was discharged and waiting of transportation to take him home. Patient 1 continued to state, "I felt blows when I was being taken down they put their knees on my neck. I said I couldn't breath. They put me on a 72 hour hold (an involuntary hold when a patient was considered a danger to himself or others)."

An interview was conducted with the Social Worker (SW) 1, on September 27, 2021, at 5:20 p.m. SW 1 stated she spoke with Patient 1 on September 24, 2021, and he told her he was "triggered by the floor staff (on September 23, 2021) and pushed the charge nurse and he knew it was his fault."

SW 1 stated she touched Patient 1's head and could feel bumps on top of his head. SW 1 stated Patient 1 told her the facility staff punched him on the back of his head and another staff twisted his arm behind his back and was kneeling on his back. SW 1 stated she observed red marks on his back and on the left side of his neck.

A review of Patient 1's record was conducted. Patient 1 was voluntarily admitted to the facility on September 20, 2021, with a diagnosis of schizoaffective disorder, bipolar type (a mental disorder characterized by abnormal thought processes, an unstable mood, and episodes of mood swings).

Further record review reflected Patient 1 received Haldol 10 mg IM, Ativan 2 mg IM, and Benadryl 50 mg IM, all to be given STAT (immediately) for agitation on September 23, 2021, at 3:15 p.m.

The record review failed to show that a seclusion/restraint packet was completed after Patient 1's take down on September 23, 2021. There was documented evidence the vital signs, assessment, or monitoring of Patient 1 was completed after the restraints were implemented on September 23, 2021.

An interview was conducted with Registered Nurse (RN) 1, on September 30, 2021, at 3 p.m. RN 1, after reviewing Patient 1's record, stated when Haldol, Ativan, and Benadryl were given on a STAT basis involuntarily to a patient, it was considered to be a chemical restraint. RN 1 further stated as with physical restraints, the seclusion/restraint packet must be completed.

RN 1 stated the seclusion/restraint packet was not completed for Patient 1. RN 1 further stated as there was no restraint packet there was no documentation to reflect Patient 1 was monitored.

3. A review of Patient 4's record was conducted. Patient 4 was admitted to the facility on September 1, 2021, with a diagnosis of schizophrenia (a mental disorder).

A review of the physician's order sheet, dated September 4, 2021, at 7:30 p.m., reflected a telephone order from the physician indicating to administer Ativan 2 mg IM, Benadryl 50 mg IM, and Haldol 10 mg IM, once, at that time. The indication for the medications was due to Patient 4's "agitation, hitting staff and trying to run."

An interview was conducted with RN 1, on September 30, 2021, at 3 p.m. RN 1 stated when Haldol, Ativan and Benadryl were given on a STAT basis involuntarily to a patient it was considered to be a chemical restraint. RN 1 further stated as with physical restraints the seclusion/restraint packet must be completed.


43559

4. During a concurrent interview and record review, on September 30, 2021, conducted with RN 1, Patient 15's record was reviewed. The "History and Physical" indicated Patient 15 was admitted to the facility on July 25, 2021, with a diagnosis of paranoid schizophrenia (a mental disorderwith heightened suspiciousness).

Patient 15's "Physician's Order," dated July 31, 2021, at 3 p.m., indicated the following:

- Administer Haldol 10 milligrams (mg) intramuscularly now;

- Administer Benadryl 50 mg IM now; and

- Administer Ativan 2 mg IM now.

Patient 15's "Medication Administration Record (MAR)," indicated the patient was administered Haldol 10 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM on July 31, 2021 at 3 p.m., for agitation and yelling at peers.

RN 1 stated the combination of Haldol, Benadryl, and Ativan, when administered IM to a patient would be considered a chemical restraint.

RN 1 stated the patient's response after restraint was applied should be documented on the restraint monitoring packet.

RN 1 stated the RN should follow the policy and procedure (P&P) when administering chemical restraints to a patient.

RN 1 stated there was no restraint monitoring packet completed when Patient 15 received chemical restraints on July 31, 2021.

5. During a concurrent interview and record review, on October 4, 2021, conducted with RN 1, Patient 23's record was reviewed. The "History and Physical" indicated Patient 23 was admitted to the facility on July 25, 2021, with a diagnosis of schizophrenia.

Patient 23's "Physician's Order," dated September 10, 2021, at 12:30 p.m., indicated the following:

- Administer Haldol 10 mg IM now;

- Administer Benadryl 50 mg IM now; and

- Administer Ativan 2 mg IM now, for increased agitation and threatening to hurt others in the day room.

Patient 23's "Medication Administration Record (MAR)," indicated Haldol 10 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM was administered to Patient 23 on September 10, 2021, at 12:30 p.m.

RN 1 stated the combination of Haldol, Benadryl, and Ativan when administered IM to a patient would be considered a chemical restraint.

RN 1 stated there should be documentation of Patient 23's response and monitoring after receiving the chemical restraint.

RN 1 stated there was no restraint monitoring packet completed on September 10, 2021.

RN 1 stated the RN should follow the policy and procedure (P&P) when administering chemical restraint to a patient.

A review of the facility's Seclusion/Restraint packet was conducted. The packet, when completed, would include the practitioner's order, observations, purpose of the restraint, duration of and criteria for the festraint, and the RN assessment to include less restrictive means used prior to the restraint/seclusion, documentation of the behavior that led to the episode, the physical/medical assessment to include vital signs, the one hour face to face assessment, and a detailed flowsheet. In addition, two documents to describe both the patient and staff debriefings were included in the packet.

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint of Patient," last reviewed in September 2019, the P&P indicated, "...Restraint...The Registered Nurse will document behaviors which led to the need for the use of restraint in the Restraint/Seclusion Packet...The RN will assign a trained staff to continuously monitor the patient during restraint. Continuously means ongoing without interruption throughout the time the patient is in restraints..."

Based on interview and record review, the facility failed to ensure the patients were seen face-to-face within one hour after restraints were applied, for five sampled patients (Patients 30, 1, 4, 15, and 23).

This failure resulted in the patients to not have an in-person evaluation and assessment of the patients' physical and psychological status after restraints were applied.

Findings:

1. During a concurrent interview and record review, on October 1, 2021, at 12:15 p.m., with the Director of Nursing (DON), Patient 30's record was reviewed. The "History and Physical" indicated Patient 30 was admitted to the facility on September 21, 2021, for psychiatric treatment.

Patient 30's "Physician's Order," dated September 21, 2021, at 5:24 p.m., indicated the following:

- Administer Haldol (medication used to treat mental and/or mood disorder) 10 milligram (mg) intramuscularly (IM, injection into the muscle) every two hours PRN for agitation or psychosis, not to exceed two doses in a day;

- Administer Benadryl (medication used for anxiety) 50 mg IM every two hours PRN for agitation or psychosis, not to exceed two doses in a day; and

- Administer Ativan (a sedative medication) 2 mg IM every two hours PRN for agitation or psychosis, not to exceed two doses in a day.

Patient 30's "Medication Administration Record," indicated the patient was administered Haldol 10 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM on the following dates and times:

- On September 23, 2021, at 10:08 p.m.;

- On September 25, 2021, at 1:22 a.m., and 3:50 p.m.;

- On September 26, 2021, at 4:30 a.m.; and

- On September 27, 2021, at 6:20 a.m.

Patient 30's "Progress Notes" indicated the following:

- "...9/26/21 (September 26, 2021) 0420 (4:20 a.m.)...pt (Patient 30) began to yell and bang room door...proceeded to offer 1:1 interaction, distraction methods and deescalation techniques. Pt. refused and proceeded to request PRN medication...PRN Haldol 10 mg IM and Ativan 2 mg IM administered on R (right) buttock...Benadryl 50 mg IM on L (left) buttock..."; and

- "...9/27/21 (September 27, 2021) 0600 (6 a.m.) Pt. became aggressive and agitated towards other patients. He (Patient 30) started hitting the walls. Pt. was verbally redirected x 3 (three times) however he became more agitated. Pt. has a order for Haldol 10 mg, Ativan 2 mg and Benadryl 50 mg IM -PRN for agitation. Pt. willingly took the IM..."

There was no documented evidence Patient 30 was seen face-to-face by a physician or other licensed provider, or by a trained registered nurse within one hour after the patient was given the IM medications (Haldol, Benadryl, and Ativan).

The DON stated the combination of Haldol, Benadryl, and Ativan when administered IM to a patient, would be considered a chemical restraint. The DON stated the patient should have a face-to-face evaluation within one hour after the restraint was applied.

The DON stated the face-to-face evaluation of the patient should be documented on the restraint monitoring packet.

The DON stated there was no restraint monitoring packet completed when Patient 30 received a chemical restraint on September 23, 25, 26, and 27, 2021. The DON stated Patient 30 was not seen face-to-face within one hour after the patient received chemical restraints on the dates mentioned above.

The DON stated the RN should follow the policy and procedure when administering chemical restraints to a patient.



22384

2. During a concurrent observation and interview on September 27, 2021, at 5 p.m., conducted with Patient 1, Patient 1 was observed seated in the facility's lobby. Patient 1 was alert, calm, his voice clear as he stated he was discharged and waiting for transportation to take him home. Patient 1 continued to state, "I felt blows when I was being taken down they put their knees on my neck. I said I couldn't breath. They put me on a 72 hour hold (an involuntary hold when a patient was considered a danger to himself or others)."

An interview was conducted with Social Worker (SW) 1, on September 27, 2021, at 5:20 p.m. SW 1 stated she spoke with Patient 1 on September 24, 2021, and he told her he was "triggered by the floor staff (on September 23, 2021) and pushed the charge nurse and he knew it was his fault."

SW 1 stated she touched Patient 1's head and could feel bumps on top of his head. SW 1 stated Patient 1 told her the facility staff punched him on the back of his head and another staff twisted his arm behind his back and was kneeling on his back. SW 1 stated she observed red marks on his back and on the left side of his neck.

A review of Patient 1's record was conducted. Patient 1 was voluntarily admitted to the facility on September 20, 2021, with a diagnosis of schizoaffective disorder, bipolar type (a mental disorder characterized by abnormal thought processes, an unstable mood, and episodes of mood swings).

Further record review reflected Patient 1 received Haldol 10 mg IM, Ativan 2 mg IM, and Benadryl 50 mg, all to be given STAT (immediately) for agitation on September 23, 2021, at 3:15 p.m.

The record review failed to show that a seclusion/restraint packet was completed after Patient 1's take down on September 23, 2021. There were no vital signs taken, assessment, or monitoring of Patient 1 after the restraints were implemented on September 23, 2021. The record failed to show a one hour face to face assessment by the physician, a licensed provider, a trained Registered Nurse (RN) was implemented.

An interview was conducted with RN 1, on September 30, 2021, at 3 p.m. RN 1, after reviewing Patient 1's record, stated when Haldol, Ativan, and Benadryl were given on a STAT basis involuntarily to a patient, it was considered to be a chemical restraint. RN 1 further stated as with physical restraints, the seclusion/restraint packet must be completed.

RN 1 stated the seclusion/restraint packet was not completed for Patient 1 and there was no documentation the one hour face to face assessment with the physician, a licensed practitioner, or a trained RN was implemented.

3. A review of Patient 4's record was conducted. Patient 4 was admitted to the facility on September 1, 2021, with a diagnosis of schizophrenia (a mental disorder).

A review of the physician's order sheet, dated September 4, 2021, at 7:30 p.m., reflected a telephone order from the physician, and indicated to administer Ativan 2 mg IM, Benadryl 50 mg IM, and Haldol 10 mg IM, once at that time. The indication for the medications was due to Patient 4's "agitation, hitting staff and trying to run."

Further record review failed to show the one hour face to face observation with a physician, a licensed practitioner, or a trained RN was conducted.

An interview was conducted with RN 1, on September 30, 2021, at 3 p.m. RN 1 stated when Haldol, Ativan, and Benadryl were given on a STAT involuntarily to a patient, it was considered to be a chemical restraint. RN 1 further stated the seclusion/restraint packet must be completed with chemical restraints.



43559

4. During a concurrent interview and record review, on September 30, 2021, conducted with RN 1, Patient 15's record was reviewed. The "History and Physical" indicated Patient 15 was admitted to the facility on July 25, 2021, with a diagnosis of paranoid schizophrenia (a mental disorder with heightened suspiciousness).

Patient 15's "Physician's Order," dated July 31, 2021, at 3:00 p.m., indicated the following:

- Administer Haldol 10 mg IM now;

- Administer Benadryl 50 mg IM; and

- Administer Ativan 2 mg IM now.

Patient 15's "Medication Administration Record (MAR)," indicated the patient was administered Haldol 10 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM on July 31, 2021 at 3:00 p.m., for agitation and yelling at peers.

There was no documented evidence Patient 15 was seen face-to-face by a physician, licensed practitioner, or a trained RN within one hour after the patient was given IM medications (Haldol, Benadryl, and Ativan).

RN 1 stated the combination of Haldol, Benadryl, and Ativan, when administered IM to a patient, would be considered a chemical restraint.

RN 1 stated the patient should have a face-to-face evaluation within one hour after the restraint was applied.

RN 1 stated the face-to-face evaluation of the patient should be documented on the restraint monitoring packet.

RN 1 stated there was no restraint monitoring packet completed when Patient 15 received chemical restraint on July 31, 2021.

RN 1 stated Patient 15 was not seen face-to-face (by a physician, a licensed practitioner, or a trained RN) within one hour after the patient received chemical restraint.

RN 1 stated the RN should follow the policy and procedure (P&P) when administering chemical restraint to a patient.

5. During a concurrent interview and record review, on October 4, 2021, conducted with RN 1, Patient 23's record was reviewed. The "History and Physical" indicated Patient 23 was admitted to the facility on July 25, 2021, with a diagnosis of schizophrenia.

Patient 23's "Physician's Order," dated September 10, 2021, at 12:30 p.m., indicated the following:

- Administer Haldol 10 mg IM now;

- Administer Benadryl 50 mg IM now; and

- Administer Ativan 2 mg IM now, for increased agitation and threatening to hurt others in the day room.

Patient 23's "Medication Administration Record (MAR)," indicated the patient was administered Haldol 10 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM on September 10, 2021, at 12:30 p.m.

There was no documented evidence Patient 23 was seen face-to-face by a physician, a licensed practitioner, or a trained RN within one hour after the patient was given IM medications (Haldol, Benadryl, and Ativan).

RN 1 stated the combination of Haldol, Benadryl, and Ativan, when administered IM to a patient, would be considered a chemical restraint.

RN 1 stated the patient should have a face-to-face evaluation within one hour after the restraint was applied.

RN 1 stated the face-to-face evaluation of the patient should be documented on the restraint monitoring packet.

RN 1 stated there was no restraint monitoring packet completed when Patient 23 received chemical restraint on September 10, 2021.

RN 1 stated the RN should follow the policy and procedure (P&P) when administering chemical restraint to a patient.

A review of the facility's Seclusion/Restraint packet was conducted. The packet, when completed, would include the practitioner's order, observations, purpose of the restraint, duration of and criteria for restraints, and the RN assessment to include less restrictive means used prior to the restraint/seclusion, documentation of the behavior that led to the episode, the physical/medical assessment to include vital signs, the one hour face to face assessment and a detailed flowsheet. In addition, two documents to describe both the patient and staff debriefings were included in the packet.

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint of Patient," last reviewed in September 2019, the P&P indicated, "...Restraint...The Registered Nurse will document behaviors which led to the need for the use of restraint in the Restraint/Seclusion Packet...A licensed Independent Practitioner or trained Registered Nurse shall conduct an in-person evaluation of the patient within one hour of initiation of restraint to assess physical and psychological status. The in-person evaluation includes the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the intervention..."

Based on interview and record review, the facility failed to ensure the patients' response to the use of restraints and the rationale for continued use of restraint were documented on the patients' record, for five sampled patients (Patients 30, 1, 4, 15 and 23).

This failure had the potential to result in the inappropriate use of restraints, unnecessary and prolonged use of restraints. This failure also the potential to violate the patients' rights.

Findings:

1. During a concurrent interview and record review, on October 1, 2021, at 12:15 p.m., conducted with the Director of Nursing (DON), Patient 30's record was reviewed. The "History and Physical" indicated Patient 30 was admitted to the facility on September 21, 2021, for psychiatric treatment.

Patient 30's "Physician's Order," dated September 21, 2021, at 5:24 p.m., indicated the following:

- Administer Haldol (medication used to treat mental and/or mood disorder) 10 milligram (mg) intramuscularly (IM, injection into the muscle) every two hours PRN for agitation or psychosis, not to exceed two doses in a day;

- Administer Benadryl (medication used for anxiety) 50 mg IM every two hours PRN for agitation or psychosis, not to exceed two doses in a day; and

- Administer Ativan (a sedative medication) 2 mg IM every two hours PRN for agitation or psychosis, not to exceed two doses in a day.

Patient 30's "Medication Administration Record," indicated the patient was administered Haldol 10 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM on the following dates and times:

- On September 23, 2021, at 10:08 p.m.;

- On September 25, 2021, at 1:22 a.m., and 3:50 p.m.;

- On September 26, 2021, at 4:30 a.m.; and

- On September 27, 2021, at 6:20 a.m.

Patient 30's "Progress Notes" indicated the following:

- "...9/26/21 (September 26, 2021) 0420 (4:20 a.m.)...pt (Patient 30) began to yell and bang room door...proceeded to offer 1:1 interaction, distraction methods and deescalation techniques. Pt. refused and proceeded to request PRN medication...PRN Haldol 10 mg IM and Ativan 2 mg IM administered on R (right) buttock...Benadryl 50 mg IM on L (left) buttock..."; and

- "...9/27/21 (September 27, 2021) 0600 (6 a.m.) Pt. became aggressive and agitated towards other patients. He (Patient 30) started hitting the walls. Pt. was verbally redirected x3 (three times) however he became more agitated. Pt. has a order for Haldol 10 mg, Ativan 2 mg and Benadryl 50 mg IM -PRN for agitation. Pt. willingly took the IM..."

There was no documented evidence of Patient 30's response to IM medications (Haldol, Benadryl, and Ativan) administered on the dates and times mentioned above.

The DON stated the combination of Haldol, Benadryl, and Ativan, when administered IM to a patient, would be considered a chemical restraint. The DON stated there should be a documentation of Patient 30's response after receiving the chemical restraint.

The DON stated the patient's response after restraint was applied should be documented on the restraint monitoring packet.

The DON stated the RN should follow the policy and procedure (P&P) when administering chemical restraint to a patient.

The DON stated there was no restraint monitoring packet completed when Patient 30 received chemical restraint on September 23, 25, 26, and 27, 2021.



22384

2. During a concurrent observation and interview on September 27, 2021, at 5 p.m., conducted with Patient 1, Patient 1 was observed seated in the facility's lobby. Patient 1 was alert, calm, his voice clear as he stated he was discharged and waiting for transportation to take him home. Patient 1 continued to state, "I felt blows when I was being taken down they put their knees on my neck. I said I couldn't breath. They put me on a 72 hour hold (an involuntary hold when a patient is a danger to himself or others)."

An interview was conducted with the Social Worker (SW) 1, on September 27, 2021, at 5:20 p.m. SW 1 stated she spoke with Patient 1 on September 24, 2021, and he told her he was "triggered by the floor staff (on September 23, 2021) and pushed the charge nurse and he knew it was his fault."

SW 1 stated she touched Patient 1's head and could feel bumps on top of his head. SW 1 stated Patient 1 told her the facility staff punched him on the back of his head and another staff twisted his arm behind his back and was kneeling on his back. SW 1 stated she observed red marks on his back and on the left side of his neck.

A review of Patient 1's record was conducted. Patient 1 was voluntarily admitted to the facility on September 20, 2021, with a diagnosis of schizoaffective disorder, bipolar type (a mental disorder characterized by abnormal thought processes, an unstable mood, and episodes of mood swings).

Further record review reflected Patient 1 received Haldol 10 mg IM, Ativan 2 mg IM, and Benadryl 50 mg IM, all to be given STAT (immediately) for agitation on September 23, 2021, at 3:15 p.m.

Further record review failed to show that vital signs and an assessment of Patient 1 were completed after the patient's restraint.

An interview was conducted with Registered Nurse (RN) 1, on September 30, 2021, at 3 p.m. RN 1, after reviewing Patient 1's record, stated when Haldol, Ativan and Benadryl were given on a STAT basis involuntarily to a patient, it was considered to be a chemical restraint. RN 1 further stated as with physical restraints the seclusion/restraint packet must be completed.

RN 1 stated the seclusion/restraint packet was not implemented for Patient 1. RN 1 further stated as such the patient's response to the chemical restraint was not documented.

3. A review of Patient 4's record was conducted. Patient 4 was admitted to the facility on September 1, 2021, with a diagnosis of schizophrenia (a term mental disorder).

A review of the physician's order sheet, dated September 4, 2021, at 7:30 p.m., reflected a telephone order from the physician indicating to administer Ativan 2 mg IM, Benadryl 50 mg IM, and Haldol 10 mg IM X 1, "now." The indication for the medications was due to Patient 4's "agitation, hitting staff and trying to run."

An interview was conducted with RN 1, on September 30, 2021, at 3 p.m. RN 1 stated when Haldol, Ativan and Benadryl were given on a "Now" basis involuntarily to a patient, it was considered to be a chemical restraint. RN 1 further stated as with physical restraints the seclusion/restraint packet must be completed.

RN 1 stated the seclusion/restraint packet was not implemented for Patient 1. RN 1 further stated as such the patient's response to the chemical restraint was not documented.



43559

4. During a concurrent interview and record review, on September 30, 2021, with RN 1, Patient 15's record was reviewed. The "History and Physical" indicated Patient 15 was admitted to the facility on July 25, 2021, with a diagnosis of paranoid schizophrenia (a mental disorder with heightened suspiciousness).

Patient 15's "Physician's Order," dated July 31, 2021, at 3:00 p.m., indicated the following:

- Administer Haldol 10 mg IM now;

- Administer Benadryl 50 mg IM now; and

- Administer Ativan 2 mg IM now.

Patient 15's "Medication Administration Record (MAR)," indicated the patient was administered Haldol 10 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM on July 31, 2021 at 3:00 p.m., for agitation and yelling at peers.

RN 1 stated the combination of Haldol, Benadryl, and Ativan, when administered IM to a patient, would be considered a chemical restraint.

RN 1 stated there should be a documentation of Patient 15's response after receiving the chemical restraint.

RN 1 stated the patient's response after restraint was applied should be documented on the restraint monitoring packet.

RN 1 stated the RN should follow the policy and procedure (P&P) when administering chemical restraint to a patient.

RN 1 stated there was no restraint monitoring packet completed when Patient 15 received chemical restraint on July 31, 2021.

5. During a concurrent interview and record review, on October 4, 2021, with RN 1, Patient 23's record was reviewed. The "History and Physical" indicated Patient 23 was admitted to the facility on July 25, 2021, with a diagnosis of schizophrenia.

Patient 23's "Physician's Order," dated September 10, 2021, at 12:30 p.m., indicated the following:

- Administer Haldol 10 mg IM now;

- Administer Benadryl 50 mg IM now; and

- Administer Ativan 2 mg IM now, for increased agitation and threatening to hurt others in the day room.

Patient 23's "Medication Administration Record (MAR)," indicated the patient was administered Haldol 10 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM on September 10, 2021, at 12:30 p.m.

RN 1 stated the combination of Haldol, Benadryl, and Ativan, when administered IM to a patient, would be considered a chemical restraint.

RN 1 stated there should be a documentation of Patient 23's response after receiving the chemical restraint.

RN 1 stated the patient's response after restraint was applied should be documented on the restraint monitoring packet.

RN 1 stated the RN should follow the policy and procedure (P&P) when administering chemical restraint to a patient.

A review of the facility's Seclusion/Restraint packet was conducted. The packet when completed would include the practitioners order, purpose of the restraint, duration of and criteria for restraint, the RN assessment to include less restrictive means used prior to the restraint/seclusion, documentation of the behavior that led to the episode, the physical/medical assessment to include vital signs, the one hour face to face assessment and a detailed flowsheet. In addition two documents to describe both the patient and staff debriefings were included in the packet.

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint of Patient," last reviewed in September 2019, the P&P indicated, "...Restraint episodes will be documented on the Restraint/Seclusion Packet which include the following forms: Restraint/Seclusion Practitioner Order, Face-to-Face Assessment, RN Restraint/Seclusion Assessment, Restraint/Seclusion Progress Note Restraint/Seclusion Flow Sheet, and Patient Debriefing and incident report."

Based on observation, interview, and record review, the facility failed to ensure there were sufficient numbers of qualified, trained, and experienced staff to safely implement the restraint process.

This failure potentially resulted in four patients (Patients 12, 9, 1, and 3) being subjected to both a physical and emotionally abusive environment.

Findings:

1. During an observation on September 28, 2021, at 3:30 p.m., in the facility lobby, Patient 12 was observed by two members of the survey team during a code white (indicating a pending emergency with a violent or combative patient) to be taken down to the ground, face down, and physically restrained by multiple staff members at each limb. Patient 12's right leg was observed to be physically restrained and held to the ground by Registered Nurse (RN) 3's left knee on the patient's right calf.

Patient 12's record was reviewed on October 1, 2021. Patient 12 was admitted to the facility on September 21, 2021, with diagnoses that included schizophrenia (a mental disorder) and autism (a developmental disability).

During an interview on September 28, 2021, at 3:40 p.m., conducted with RN 3, RN 3 stated he used his knee to physically restrain Patient 12's right leg after the patient was taken down to the ground. RN 3 stated this was a mistake. RN 3 stated knees should not be used to physically restrain patients and only hands should be used.

During an interview on September 29, 2021, at 10 a.m., conducted with the Director of Nursing (DON), the DON stated knees should never be used to physically restrain or contain patients. The DON stated only hands should be used when physical restraints are needed.

2. On September 29, 2021, Patient 9's record was reviewed. Patient 9 was admitted to the facility on September 21, 2021, with the diagnosis of schizophrenia.

Patient 9's "Seclusion/Restraint Packet," dated September 27, 2021, at 3 p.m., indicated the physician ordered mechanical and chemical restraints for Patient 9.

During an interview on September 28, 2021, at 1 p.m., conducted with Registered Nurse (RN) 1, RN 1 stated when a patient was physically restrained on the floor, the correct way to transfer the patient was by either escorting the patient onto his feet by holding the shoulder/arms or by using the gurney and flipping the patient over face up.

RN 1 stated he has seen patients at the facility being transferred face down by being lifted and carried by their limbs.

RN 1 stated it is very unsafe to transfer patients in this manner since it can cause hyperextension (the forceful extension of a limb or joint beyond its normal limits) and pain to the patient.

During an interview on September 28, 2021, at 4:20 p.m., conducted with Social Worker (SW) 1, SW 1 stated she was a witness to Patient 9's takedown to the ground and transfer from the floor to the restraint/seclusion room on September 27, 2021. SW 1 stated she witnessed Patient 9 transferred from the ground by four staff, one at each limb. SW 1 stated each staff member grabbed one of Patient 9's limbs, lifted the patient into the air, while the patient was face down, and carried him this way down the hallway, past the nurse's station, to the restraint/seclusion room. SW 1 further stated she verbalized to the staff they needed to stop because they were going to break his spine, but the staff ignored her.

During an interview on October 1, 2021, at 9:10 a.m., with the Director of Nursing (DON), the DON stated there was no specific education or hands-on training provided to staff regarding the transfer of patients who are physically restrained on the floor.

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint of Patient," with a revised date of September 2019, the P&P indicated, "...Staff Competency and Education...Employees must demonstrate competency in [MAB and Seclusion & Restraint] procedures...The focus of training is...containment techniques, including escort procedures..."



22384

3. During a concurrent observation and interview, on September 27, 2021, at 5 p.m. Patient 1 was observed seated in the facility's lobby. Patient 1 was alert, calm, his voice clear, as he stated he was discharged and waiting for transportation to take him home. Patient 1 stated, "I felt blows when I was being taken down, they put their knees on my neck. I said I couldn't breathe. They put me on a 72 hour hold (a 5150 involuntary hold when a patient is a danger to himself or others)."

Patient 1 further stated, "The social worker was very upset to see what happened to me. I was chicken winged (when a patient is positioned prone in the chicken wing position, the shoulder is in retroversion and maximum internal rotation and adduction, and the hand is behind the back), and they were (facility staff) were standing on the back of my feet. I have bumps on my head and my ribs hurt on my left side."

A review of Patient 1's record was conducted. Patient 1 was voluntarily admitted to the facility on September 20, 2021, with a diagnosis of Schizoaffective disorder, bipolar type (a mental disorder characterized by abnormal thought processes, an unstable mood and episodes of mood swings).

An interview was conducted with Registered Nurse (RN) 4, on September 27, 2021, at 3 p.m. RN 4 stated on September 23, 2021, around 3:30 p.m., a code white (indicating a pending emergency with a violent or combative patient) regarding Patient 1 was called . RN 4 further stated Patient 1 was cursing and threatening others.

An interview was conducted with Social Worker (SW) 1, on September 27, 2021, at 5:20 p.m. SW 1 stated she spoke with Patient 1 on September 24, 2021, and he told her he was "Triggered by the floor staff (on September 23, 2021) and pushed the charge nurse and he knew it was his fault."

SW 1 stated she touched Patient 1's head and could feel bumps on top of his head. SW 1 stated Patient 1 told her the facility staff punched him on the back of his head and another staff twisted his arm behind his back and was kneeling on his back. SW 1 stated she observed red marks on his back and on the left side of his neck.

An interview was conducted with Behavioral Health Associate (BHA) 1 on September 28, 2021, at 11 a.m. BHA 1 stated he was the target of Patient 1, when the patient became agitated last week on September 23, 2021. BHA 1 saw a staff member grab Patient 1's arm and put him to the ground.

BHA 1 further stated he had worked at the facility for 9 months and before being hired, he had no prior training in mental health.

BHA 1 stated he had MAB (Management of Assaultive Behavior) training but did not have ongoing training in how to physically restrain a patient or how to place restraints on a patient.

BHA 1 stated he did not have an opportunity to practice hands-on techniques for restraining of patients. BHA 1 stated he would watch other staff to learn the takedown/restraint process.

BHA 1 stated he had put his knees on patient's arms or legs to restrain them and he had seen patients being picked up [while on their stomach] by their arms and legs.

An interview was conducted with the Director of Nursing (DON), on September 28, 2021, at 2 p.m. The DON stated during the process of restraining a patient, only a person's hands should be used to restrain a patient. The DON stated knees should never be placed on the patient's neck, back, or anywhere on the patient.

4. A review of Patient 3's record was conducted. Patient 3 was admitted to the facility on September 21, 2021, with a diagnosis of Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).

An interview was conducted with Behavioral Health Associate (BHA) 2 on September 27, 2021, at 1:30 p.m. BHA 2 stated he was involved in a restraint episode involving Patient 3 when the patient swung at him and was using vulgar language.

BHA 2 said he was able to take the patient down to the floor. BHA 2 stated BHA 1 and Registered Nurse (RN) 4 came into the room. BHA 2 stated they transferred the patient to the bed by holding her arms and legs while in a prone position.

BHA 2 stated this was the first time he "took down" a patient and no one had taught him how to do that. BHA 2 stated he was not involved in the staff debriefing process after Patient 3's restraint episode.

An interview was conducted with the Director of Nursing (DON), on September 28, 2021, at 2 p.m. The DON stated during every restraint episode, a staff debriefing should be conducted to follow up on any problems encountered during the restraint process and all staff involved should be present at the debriefing. The DON stated the findings during the staff debriefing process would be used for education and training purposes.

An interview was conducted with the Marriage and Family Therapist (MFT) on September 27, 2021, at 12 p.m. The MFT stated she was present during a restraint episode involving Patient 3. She further stated during the restraint episode she observed BHA 2 placing his knee on the Patient 3's neck and shoulder area.

An interview was conducted with BHA 1 on September 28, 2021, at 11:00 a.m. BHA 1 stated he was involved with the restraint episode involving Patient 3 on September 23, 2021. BHA 1 stated he went to assist BHA 2 with Patient 3 as the patient was cursing and agitated.

BHA 1 stated he had worked at the facility for 9 months and before being hired, he had no prior training in mental health.

BHA 1 stated he had MAB (Management of Assaultive Behavior) training but did not have ongoing training in how to physically restrain a patient or how to place restraints on a patient.

BHA 1 stated he did not have an opportunity to practice hands-on techniques for restraining of patients. BHA 1 stated he would watch other staff to learn the takedown/restraint process.

BHA 1 stated he had put his knees on patient's arms or legs to restrain them and he had seen patients being picked up [while on their stomach] by their arms and legs.

BHA 1 stated he helped other staff transfer Patient 3 to the bed. BHA 1 stated he grabbed Patient 3's arm and leg while she was lying on her stomach and assisted the staff in transferring the patient on the bed while she remained in a face down position.

An interview was conducted with the DON, on September 28, 2021, at 2 p.m. The DON stated during the process of restraining a patient only a person's hands and body weight should be used to restrain a patient The DON stated knees or elbows should never be placed on the patient's neck, back, or anywhere on the patient.

An interview was conducted with Registered Nurse (RN) 1 on September 30, 2021, at 4 p.m., who stated prior to transferring a patient during a restraint episode, the patient must be rolled onto their back and placed onto a backboard or gurney to transfer the patient onto a bed. RN 1 further stated if a patient is transferred in a face down position the patient could hit their head on the floor.

An interview was conducted with the DON on September 29, 2021, at 9:20 a.m. The DON stated the BHAs are not utilizing the resources present in the facility to assist with patient transfers, such as using the backboards to safely transfer patients.

A review of the facility's job description for a Behavioral Health Associate indicated the Purpose Statement as: "...Responsible for providing personal care services to patients at the facility under the direction of clinical or nursing leadership...Recognize that patient safety is a top priority. Education/Experience/Skill Requirements: High school diploma or equivalent required. Six month or more experience working with the specific population of the facility preferred..."

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint of Patient," with a revised date of September 2019, the P&P indicated, "...To provide guidelines for the appropriate use of seclusion and/or restraint in clinically justified circumstances. To provide guidelines for patient monitoring and care in order to promote patient safety, protection, and to maintain the patient's rights and dignity. To ensure that restraint and/or seclusion procedures conform with all accrediting standards and State and Federal regulations and to guarantee all patients their human and civil rights. Hospital leadership strives to minimize the use of restraint and whenever possible to eliminate its use through staff training, thorough assessment, effective treatment planning, management of the environment, and ongoing performance improverment efforts..."

The policy indicated, "It is the policy of (the facility) to limit the use of seclusion and/or restraint to emergencies in which there is an imminent risk of a patient physically harming himself/herself or others, including staff. Seclusion or restraint will only be employed after the use of less restrictive, non-physical measures, and have proven unuccessful in modifying the behavior for which the use of seclusion and/or restraint is considered. Seclusion and/or restraint shall be discontinued as soon as possible. The patient's rights, dignity, safety, and well being will be supported and maintained. Seclusion and/or restraint will not be used as a punitive measure or as a means of coercion, discipline, convenience or retaliation by staff."

The policy also indicated, "The Registered Nurse will document behaviors which led to the need for the use of restraint in the Restraint/Seclusion Packet. Patients will be physically restrained in the supine positon, unless contraindicated and in accordance with MAB (Management of Assaultive Behavior Course), Approved MAB holds are considered a physical restraint."

The policy further indicated, "Staff who witnessed the precipitating events and/or who were involved in the restraint process will participate in the staff team debriefing session. Staff debriefing is to be documented on the Staff Team Debriefing form...Staff Competency and Education...Employees must demonstrate competency in [MAB and Seclusion & Restraint] procedures...The focus of training is...containment techniques, including escort procedures...""

During a review of the facility's MAB educational booklet titled, "MAB M2 Clinical Containment Program," undated, the booklet indicated, "...Any behavioral intervention must be consistent with the Patient's rights to be treated with dignity and to be free from abuse...The Response Team focuses on the prevention of un-needed pressures on the patient during the containment process..." There was no documentation in the booklet that indicated knees

Based on interview and record review, the facility failed to ensure performance improvement activities included indicators to track the performance of staff applying MAB (Management of Assaultive Behavior) techniques in physical restraint take downs and the transfer of patients who were physically restrained on the floor (A 283).

The extreme effect of this failure resulted in the identification of immediate jeopardy related to the unsafe use of physical restraints, unsafe transfer of patients who were physically restrained on the floor, a violation of patients' rights, and the potential for harm or death to the patients.

On September 28, 2021, at 4:20 p.m., the Chief Executive Officer (CEO), and the Director of Quality and Risk Management (DQRM), were notified of the determination of an immediate jeopardy situation to the health and safety of patients related to unsafe practices used during the restraint process.

The facility developed a plan of correction, and the CEO and the DQRM were notified the facility's plan of action was accepted on September 28, 2021, at 6:05 p.m.

On September 29, 2021, at 9:45 a.m., implementation of the plan of action was verified onsite and the CEO and the DQRM were notified that the Immediate Jeopardy situation was abated. (Refer to A 115).

The plan of action ensured:

1. All patient care staff will be retrained in safe patient handling to include properly transferring patients from the ground to the restraint gurney or restraint bed.

2. Physical holds, proper restraint of patients, inappropriate to use knees to hold patients down: All patient care staff will be retrained on not using knees to physically hold a patient down.

3. Proper restraint of a combative patient, hands-on education of and training of all employees on the proper restraint of a combative patient: A member of the leadership team will be assigned to conduct a debriefing with staff involved in a take down.

The plan of action indicated all seclusion and restraint events will be analyzed and deficient practices will be reported to the Quality Council monthly, Medical Executive Committee quarterly, and Governing Board.



22384

Based on interview and record review, the facility failed to ensure performance improvement activities included indicators to track the performance of staff applying MAB (Management of Assaultive Behavior) techniques in physical restraint takedowns and the transfer of patients who were physically restrained on the floor.

This failure resulted in the identification of immediate jeopardy related to the unsafe use of physical restraints, unsafe transfer of patients who were physically restrained on the floor, a violation of patients' rights, and the potential for harm or death to patients.

Findings:

During an interview on September 28, 2021, at 12 p.m., conducted with the Director of Nursing (DON), the DON stated the staff education for MAB and restraints were modified. The DON stated the education included both classroom instruction and hands-on training, but was extremely limited or non-existent.

During a follow up interview on October 1, 2021, at 9:10 a.m., conducted with the DON, the DON stated there was no education provided to staff members during new hire orientation or on the nursing units regarding the safe transfer of patients who were physically restrained on the floor. The DON further stated no one verified if staff were competent in these types of transfers.

During a review of the facility's performance improvement minutes, with a date range of January 2021 through July 2021, there was no documentation indicating data for restraint education or the safe implementation of restraints was being reviewed, discussed, and/or monitored by the facility.

On October 4, 2021, at 1:55 p.m., representatives from the Quality Committee were interviewed. During the interview, the DON stated there was no data or quality indicators for the safe implementation of physical restraints or transfers of patients included in the performance improvement program because the process had not been identified as needing improvement.

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint of Patient," with a revised date of September 2019, the P&P indicated, "...the Performance Improvement Program includes collecting data on the use of seclusion and/or restraint in order to monitor and improve its performance of processes that involve risks or may result in sentinel events...To identify opportunities for incrementally improving the rate and safety of seclusion and/or restraint use..."

During a review of the facility's document titled, "Process Improvement Program," with a last revised date of February 2021, the document indicated, "...Objectives are...To support effective systems and a learning environment in the pursuit of zero harm...To maximize clinical performance...through...orientation, training, and continuing education...The Quality Council is the steering committee for the Program and will...ensure implementation of process improvement activities through resources, training, and education..."

Based on observation, interview, and record review, the facility failed to ensure:

1. There were adequate numbers of staff in accordance with patient acuities (a measurement of the intensity of nursing care needed by patients) for multiple dates, shifts, and nursing units (A 392);

2. Complete assessments and reassessments were conducted by the nursing staff, for three sampled patients (Patients 2 and 10) (A 395);

3. Patient 3's documentation of safety observations were accurate (A 395);

4. The documentation of safety observations were signed by the Registered Nurse (RN), for 20 sampled patients (Patients 1, 2, 3, 4, 9, 10, 12, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 27, and 28) (A 395);

5. The records for Activities of Daily Living (ADLs) were completed, for 8 sampled patients (Patients 15, 16, 17, 18, 19, 20, 23, and 24) (A 395);

6. Adequate supervision and evaluation of staff in MAB (Management of Assaultive Behavior) techniques, physical restraint takedowns, and the transfer of patients who were physically restrained on the floor were provided (A 398);

7. The laboratory tests were completed as ordered by the physician, for one sampled patient (Patient 26) (A 398);

8. The medications were administered as ordered by the physician, for Patients 25, 28, 3, 4, 8, 9, 10, 14, 18, 21, and 23 (A 405);

9. Assessment and reassessment were conducted when medications on as needed (prn) basis were administered to Patients 28, 30, 6, 7, 8, 10, 13 and 14 (A 405);

10. The physician was notified when the patient refused to take Synthroid (thyroid medication) and Depakote (medication used to treat seizure), for one sampled patient (Patient 26) (A 405);

11. The patient's physician was notified when the patient refused to take Synthroid (thyroid medication) and Depakote (medication used to treat seizure), for one sampled patient (Patient 26).

The cumulative effect of these systemic problems resulted in a failure to ensure the nursing service staff was trained and able to provide quality care.

On September 28, 2021, at 4:20 p.m., the Chief Executive Officer (CEO), and the Director of Quality and Risk Management (DQRM), were notified of the determination of an immediate jeopardy situation to the health and safety of patients related to unsafe practices used during the restraint process.

The facility developed a plan of action, and the CEO and the DQRM were notified the facility's plan of action was accepted on September 28, 2021, at 6:05 p.m.

On September 29, 2021, at 9:45 a.m., the implementation of the plan of action was verified onsite and the CEO and the DQRM were notified that the immediate jeopardy situation was abated (Refer to A 115).

The plan of action indicated:

1. All patient care staff will be retrained in safe patient handling to include properly transferring patients from the ground to the restraint gurney or restraint bed.

2. Physical holds, proper restraint of patients, inappropriate to use knees to hold patients down: All patient care staff will be retrained on not using knees to physically hold a patient down.

3. Proper restraint of a combative patient, hands-on education of and training of all employees on the proper restraint of a combative patient: A member of the leadership team will be assigned to conduct a debriefing with staff involved in a take down.

The plan of action also indicated all seclusion and restraint events will be analyzed and deficient practices will be reported to thre Quality Council monthly, Medical Executive Committee quarterly, and Governing Board.

Based on interview and record review, the facility failed to ensure there were adequate numbers of staff in accordance with patient acuities (a measurement of the intensity of nursing care needed by patients) for multiple dates, shifts, and nursing units.

This failure had the potential to result in the patients' needs to not be met, delay in treatment, and an overall risk to the quality of patient care.

Findings:

During an interview and record review, on October 1, 2021, at 3 p.m., conducted with the Director of Nursing (DON), staff assignments and patient acuities were reviewed. The DON stated patient acuities were completed by the charge nurses two hours before the start of the shift. The DON stated the acuity number determined the same number of staff needed to care for patients on that specific unit and shift.

The DON stated there were not enough staff for patient care in accordance to patient acuity for the following dates, shifts, and nursing units:

- For the day shift (7 a.m. to 7 p.m.) of September 23, 2021, the Mission unit had a patient acuity of six (six staff were needed to do patient care) and only five staff were assigned to the unit;

- For the day shift of September 24, 2021, the Arlington unit had a patient acuity of seven (seven staff were needed to do patient care) and only six staff were assigned to the unit;

- For the night shift (7 p.m. to 7 a.m.) of September 24, 2021, the Arlington unit had a patient acuity of five (five staff were needed to do patient care) and only four staff were assigned to the unit; and

- For the night shift of September 24, 2021, the Mission unit had a patient acuity of six and only five staff were assigned to the unit.

During an interview and record review on October 4, 2021, at 11:05 a.m., conducted with Registered Nurse (RN) 1, additional staff assignments and acuities for the nursing units were reviewed. RN 1 stated there were not enough staff according to the patient acuities for the following dates, shifts, and nursing units:

- For the day shift of September 10, 2021, the Magnolia unit had a patient acuity of five and only four staff were assigned to the unit;

- For the night shift of September 10, 2021, the Mission unit had a patient acuity of five and only four staff were assigned to the unit;

- For the night shift of September 16, 2021, the Mission unit had a patient acuity of six and only five staff were assigned to the unit;

- For the night shift of September 16, 2021, the Magnolia unit had a patient acuity of five and only four staff were assigned to the unit;

- For the day shift of September 19, 2021, the Mission unit had a patient acuity of seven and only six staff were assigned to the unit; and,

- For the night shift of September 25, 2021, the Mission unit had a patient acuity of six and only five staff were assigned to the unit.

During a review of the facility's policy and procedure (P&P) titled, "Patient Classification/Nursing Staffing Plan," with a reviewed date of January 2021, the P&P indicated, "...To ensure quality nursing care and safe patient environment by establishing an acuity system to determine an appropriate staffing pattern based on the assessment of patient needs...The Patient Classification Acuity form will be completed each shift by the unit RN two hours prior to the oncoming shift utilizing the guidelines on the form...The charge nurse refers to the Patient Classification Acuity form which has predetermined acuity hours appropriate for the delivery of quality nursing care...The total number of patients on each level of care is multiplied by the established number of hours, for each shift. The total number of hours will then be divided by 12 to determine the number of staff required...The necessary staffing mix will be determined by the charge nurse upon review of the patient acuity levels..."

Based on interview and record review, the facility failed to ensure:

1. Complete assessments and reassessments were conducted by the nursing staff in accordance with the facility's policy and procedure, for two sampled patients (Patients 2 and 10);

2. The documentation of safety observations were accurate, for one patient (Patient 3);

3. The documentation of safety observations were signed by the Registered Nurse (RN), for 20 sampled patients (Patients 1, 2, 3, 4, 9, 10, 12, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 27, and 28).

4. The records for Activities of Daily Living (ADLs) were completed, for 11 sampled patients (Patients 9, 10, 12, 15, 16, 17, 18, 19, 20, 23, and 24).

These failed practices potentially impacted patient safety and the quality and provision of overall patient care.

Findings:

1a. A review of Patient 2's record was conducted. Patient 2 was admitted to the facility on September 13, 2021, with a diagnosis of depression (a mood disorder). Patient 2 was discharged on September 16, 2021.

A review of the "History and Physical," dated September 13, 2021, indicated the patient was admitted with self inflicted wounds to the left upper extremity and right thigh. The physician indicated, "...Self induced wounds of left upper extremity and right lower extremity. Superficial. Healing. Monitor..."

There was no documented evidence Patient 2's self-inflicted wounds upon admission or prior to discharge was assessed by a registered nurse. There was no documented evidence photographs of the wounds were taken upon admission and discharge.

An interview was conducted with the Director of Nursing (DON) on September 29, 2021, at 4:30 p.m. The DON stated a complete assessment of Patient 2's wounds should have been completed, as well as pictures taken, upon admission and prior to discharge.

b. On September 30, 2021, Patient 10's record was reviewed. Patient 10 was admitted to the facility on April 29, 2021, with a diagnosis of bipolar disorder (a mental illness marked by extreme shifts in mood).

Patient 10's "Interdisciplinary Treatment Plan," initiated on May 2, 2021, indicated, "...Problem: Impaired skin integrity related to superficial wound..."

The nursing note, dated May 7, 2021, at 12:30 p.m., indicated, "Patient's (Patient 10's) right and left hand appear to be swollen with multiple cuts and scratches..."

The nursing note, dated May 8, 2021, at 12:10 p.m., indicated, "Pt's hands are swollen with abrasions on palm/fingers/top of hands..."

The nursing skin assessment, dated May 9, 2021, at 8:40 a.m., indicated, "...Hands are a bit swollen, has bite marks..."

The physician's order, dated May 9, 2021, at 7:50 p.m., indicated to apply Neosporin ointment (an antibacterial medication used to prevent infection) topically (application to body surface, such as skin) to hands four times a day for five days.

The physician's telephone order, dated May 22, 2021, at 10 p.m., indicated to apply Neosporin ointment topically to pustules (a small collection of pus [yellowish fluid] in the top layer of skin) every 12 hours for five days.

There was no documentated evidence skin assessments were conducted by a registered nurse for Patient 10 during the night shift (7 p.m. to 7 a.m.) from May 2, 2021, through May 24, 2021. There was no documentation that indicated photograph/s of Patient A's wound was taken.

During an interview on September 30, 2021, at 9:15 a.m., conducted with the DON, the DON reviewed Patient 10's record, and stated there were no skin assessments completed for the night shifts between May 2, 2021, through May 24, 2021.

The DON further stated if a patient has a skin integrity problem identified on the treatment plan, the skin should be assessed every shift.

During an interview on September 30, 2021, at 11:40 a.m., conducted with Registered Nurse (RN) 1, RN 1 reviewed Patient 10's record, and stated he was unable to find any photographs of Patient 10's wounds.

RN 1 stated photographs should be taken when wounds were present on admission or were identified during the hospital stay.

During a review of the facility's policy and procedure (P&P) titled, "Assessment and Reassessment," revised in February 2021, the P&P indicated, "...Reassessments are completed by a Registered Nurse on day and evening shifts and documented on the Nursing Reassessment form (minimum of 2 times per calendar day)...There should be a focus on problems identified in the Interdisciplinary Treatment plan..."

During a review of the facility's P&P titled, "Wound Care," revised in October 2020, the P&P indicated, "...Admission and New Wound & Bruise Reporting...all wounds and any suspicious bruising will be assessed by nursing staff and will be documented by picture of the wound or suspicious bruise with measurements included, using a disposable measuring tape...Document wound assessment data in nursing note: wound appearance, size, drainage, etc....Retake picture when patient is discharge and every Sunday night for progression of wound..."

2. A review of Patient 3's record was conducted. Patient 3 was admitted to the facility on September 21, 2021, with a diagnosis of bipolar disorder.

A review of the Social Work/Therapy Group "Progress Notes" indicated the following:

- On September 23, 2021, from 3 p.m. to 3:30 p.m., Patient 3 was present and an active participant in the group process;

- On September 28, 2021, from 11:10 a.m. to 12 p.m., Patient 3 was present and an active participant in the group process; and,

- On September 28, 2021, from 1:05 p.m. to 1:55 p.m., Patient 3 was present and an active participant in the group process.

A review of Patient 3's observation documentation indicated the following:

- On September 23, 2021, from 3 p.m. to 3:30 p.m., Patient 3 was in her room;

- On September 28, 2021, from 11:10 a.m. to 12 p.m., Patient 3 was first in a leisure activity and then was in the hallway pacing; and,

- On September 28, 2021, from 1:05 p.m. to 1:55 p.m., Patient 3 was in her room, sitting or lying down.

An interview was conducted with the DON on September 30, 2021, at 10:15 a.m., who stated Patient 3's observation documentations were not accurate.

During a review of the facility P&P titled, "Precaution and Observations of Patients," revised in October 2020, the P&P indicated, "...A level of Observation is defined as an intensified level of staff awareness and attention to patient safety/security needs requiring the initiation of specific protocols and supplemental documentation. It is the policy of (the facility) to provide a safe and secure environment for patients during their hospitalization...Observation on an every 15 or 5 minutes or greater, frequency. Guidelines for implementation of this level of observation include, but are not limited to the following: Staff should monitor the patient's condition on a frequency level as ordered by the physician (every 15 minutes, for example)..."

3a. A review of Patient 1's record was conducted on September 27, 2021. Patient 1 was admitted to the facility on September 20, 2021, with a diagnosis of schizoaffective disorder (a mental disorder characterized by abnormal thought processes and an unstable mood).

A review of observation documentation was conducted. There was no documented evidence the RN reviewed the document throughout the patient's hospitalization.

b. A review of Patient 2's record was conducted. Patient 2 was admitted to the facility on September 13, 2021, with a diagnosis of depression. Patient 2 was discharged on September 16, 2021.

A review of the observation documentation was conducted. There was no documented evidence the RN reviewed the documents throughout the patient's hospitalization.

c. A review of Patient 3's record was conducted. Patient 3 was admitted to the facility on September 21, 2021, with a diagnosis of bipolar disorder.

A review of the observation documentation was conducted. There was no documented evidence the RN reviewed the documents throughout the patient's hospitalization.

d. A review of Patient 4's record was conducted. Patient 4 was admitted to the facility on September 1, 2021, with a diagnosis of schizophrenia (a mental disorder).

A review of the observation documentation was conducted. There was no documented evidence the RN reviewed the documents throughout the patient's hospitalization.

An interview was conducted with the DON on September 30, 2021, at 10 a.m. The DON stated the patient observation document must be signed by the Registered Nurse to verify its accuracy and to compare the patient's level of observation with the current physician's order.



42082

e. On September 29, 2021, Patient 9's record was reviewed. Patient 9 was admitted to the facility on September 21, 2021, with the diagnosis of schizophrenia.

During a review of Patient 9's "Patient Observations," dated September 21, 2021, the observation sheet indicated, "...I verified that precautions and observations match current physician order...RN Print Name: (blank)...RN Signature: (blank)..."

Further review of the patient record showed there were no RN signatures for the daily observation sheets on September 22, 2021, through September 28, 2021.

f. On September 30, 2021, Patient 10's record was reviewed. Patient 10 was admitted to the facility on April 29, 2021, with the diagnosis of bipolar disorder.

During a review of Patient 10's "Patient Observations," dated April 29, 2021, the observation sheet indicated, "...By signing below I verify that this patient's documentation and observations are accurate and complete...(the document did not indicate an RN signature)..."

Further review of the patient record showed there were no RN signatures for the daily observation sheets on April 29, 2021, through May 4, 2021; and on May 8, 2021, through May 23, 2021.

g. Patient 12's record was reviewed on October 1, 2021. Patient 12 was admitted to the facility on September 21, 2021, with diagnoses that included schizophrenia and autism (a developmental disability which could cause significant social, communication, and behavioral challenges).

During a review of Patient 12's "Patient Observations," dated September 22, 2021, the observation sheet indicated, "...I verified that precautions and observations match current physician order...RN Print Name: (blank)...RN Signature: (blank)..."

Further review of the patient record showed there were no RN signatures for the daily observation sheets on September 23, 2021, through September 28, 2021.

During an interview on September 29, 2021, at 2 p.m. with the DON, the DON stated the RNs sign the bottom of the observation sheets after they verified the frequency of observations and precautions coincided with the physician's order. The DON stated all observation sheets should be signed by a RN every day when new sheets were started or if there was a change in the physician's order.

h. On September 30, 2021, Patient 15's record was reviewed. Patient 15 was admitted to the facility on July 25, 2021, with a diagnosis of paranoid schizophrenia (a mental disorder with heightened suspiciousness). Patient 15 was discharged from the facility on August 12, 2021.

Patient 15's "Patient Observation" record indicated there was no RN signature verifying the precautions and observations matched current physician orders on the following dates:

- July 26 - 31, 2021;

- August 1 - 7, 2021; and,

- August 10 - 12, 2021.

i. On October 1, 2021, Patient 16's record was reviewed. Patient 16 was admitted to the facility on August 27, 2021, with a diagnosis of depression.

Patient 16's "Patient Observation" record, indicated there was no RN signature indicating the precautions and observations matched current physician orders on the following dates:

- August 28 to 31, 2021; and,

- September 1 to 3, 2021.

j. On October 1, 2021, Patient 17's record was reviewed. Patient 17 was admitted to the facility on August 17, 2021, with a diagnosis of schizophrenia.

Patient 17's "Patient Observation" record, indicated there was no RN signature indicating the precautions and observations matched current physician orders on the following dates:

- August 17 to 30, 2021.

k. On September 30, 2021, Patient 18's record was reviewed. Patient 18 was admitted to the facility on July 21, 2021, with a diagnosis of depression.

Patient 18's "Patient Observation" record, indicated there was no RN signature indicating the precautions and observations matched current physician orders on the following dates:

- July 22 to 28, 2021.

l. On September 30, 2021, Patient 19's record was reviewed. Patient 19 was admitted to the facility on September 13, 2021, with the diagnosis of schizophrenia.

Patient 19's "Patient Observation" record, indicated there was no RN signature indicating the precautions and observations matched current physician orders on the following dates:

- September 13 to 17, 2021.

m. On September 30, 2021, Patient 20's record was reviewed. Patient 20 was admitted to the facility on July 31, 2021, with the diagnosis of schizophrenia.

Patient 20's "Patient Observation" record, indicated there was no RN signature indicating the precautions and observations matched current physician orders on the following dates:

- August 3 to 7, 2021; and,

- August 9 to 10, 2021.

n. On October 1, 2021, Patient 21's record was reviewed. Patient 21 was admitted to the facility on September 8, 2021, with a diagnosis of schizophrenia.

Patient 21's "Patient Observation" record, indicated there was no RN signature indicating the precautions and observations matched current physician orders on the following dates:

- September 9 to 11, 2021.

o. On October 1, 2021, Patient 22's record was reviewed. Patient 22 was admitted to the facility on September 2, 2021, with a diagnosis of depression.

Patient 22's "Patient Observation" record, indicated there was no RN signature indicating the precautions and observations matched current physician orders on the following dates:

- September 2 to 4, 2021.

p. On October 1, 2021, Patient 23's record was reviewed. Patient 23 was admitted to the facility on September 7, 2021, with a diagnosis of depression.

Patient 23's "Patient Observation" record, indicated there was no RN signature indicating the precautions and observations matched current physician orders on the following dates:

- September 8 to 23, 2021.

q. On September 30, 2021, Patient 24's record was reviewed. Patient 24 was admitted to the facility on September 9, 2021, with a diagnosis of schizophrenia.

Patient 24's "Patient Observation" record, indicated there was no RN signature indicating the precautions and observations matched current physician orders on the following dates:

- September 9 to 14, 2021.

r. During a concurrent interview and record review, on September 30, 2021, at 11 a.m., with RN 1, Patient 26's record was reviewed. The "History and Physical," indicated Patient 26 was admitted to the facility on August 27, 2021, for psychiatric treatment.

Patient 26's "Inpatient Admission Orders," dated August 27, 2021, indicated, "...Observation: Q (every) 15 (minutes)..."

Patient 26's "Patient Observations Record" indicated the patient was observed every 15 minutes and was on suicide precautions. There was no RN signature on each of the record from August 27, 2021, to September 28, 2021.

RN 1 stated the record should be signed by the RN to verify the patient was on the appropriate observation monitoring time and the appropriate precautions as ordered by the physician.

RN 1 stated Patient 26's observation record was not signed by the RN.

s. During a concurrent interview and record review, on September 30, 2021, at 10 a.m., with RN 1, Patient 27's record was reviewed. The "History and Physical," indicated Patient 27 was admitted to the facility on September 24, 2021, for psychiatric treatment.

Patient 27's "Patient Observations Record" indicated the patient was observed every 15 minutes and was on suicide precautions. There was no RN signature on each of the record from September 24 to 28, 2021.

RN 1 stated the record should be signed by the RN to verify the patient was on the correct observation monitoring time and correct precautions.

RN 1 stated Patient 26's observation record was not signed by the RN.

t. During a concurrent interview and record review on October 1, 2021, at 11 a.m., with the DON, Patient 28's record was reviewed. The "History and Physical" indicated Patient 28 was admitted to the facility on August 9, 2021, for medication overdose.

Patient 28's "Patient Observations Record" indicated the patient was observed every 15 minutes and was on suicide precautions. There was no RN signature on each of the record from August 9 to 14, 2021.

The DON stated the record should be signed by the RN to verify the patient was on the correct observation monitoring time and correct precautions.

The DON stated Patient 28's observation record was not signed by the RN.

During a review of the facilty's P&P titled, "Precautions and Observations of Patients," revised in October 2020, the P&P indicated, "...An order for the appropriate level of observation and precautions should be documented in the physician's order section of the medical record, and the Rounds Sheets should be initiated by the Charge nurse or designee..."

4a. On September 29, 2021, Patient 9's record was reviewed. Patient 9 was admitted to the facility on September 21, 2021, with the diagnosis of schizophrenia.

Patient 9's "Patient Monitoring Graphic Form," dated September 22, 23, 25, and 26, 2021, for day shift (7 a.m. to 7 p.m.) and for night shift (7 p.m. to 7 a.m.) were reviewed. There were no staff initials nor documentation in the boxes for Patient 9's hygiene and sleep which would indicate Patient 9 had a shower/bath, was assisted with ADLs, or had slept for a certain duration of hours.

b. On September 30, 2021, Patient 10's record was reviewed. Patient 10 was admitted to the facility on April 29, 2021, with the diagnosis of bipolar disorder.

Patient 10's "Patient Monitoring Graphic Form," indicated there were no staff initials or documentation in the boxes for Patient 10's hygiene and sleep which would indicate Patient 10 had a shower/bath, was assisted with ADLs, or had slept for a certain duration of hours, for the following dates and times:

- Day shift for April 30, 2021;

- Day shift for May 13 and 14, 2021;

- Night shift for May 3, 6, 10, 11, 16, and 17, 2021; and,

- Both day and night shift for May 1, 2, 4, 5, 8, 9, 12, 15, 18, 20, 22, and 24, 2021.

c. Patient 12's record was reviewed on October 1, 2021. Patient 12 was admitted to the facility on September 21, 2021, with diagnoses that included schizophrenia.

Patient 12's "Patient Monitoring Graphic Form," dated September 21, 22, 23, 25, 26, 27, and 28, 2021, for day and night shift was reviewed. There were no staff initials or documentation in the boxes for Patient 12's hygiene and sleep which would that indicate Patient 12 had a shower/bath, was assisted with ADLs, or slept for a certain duration of hours.

During an interview on September 29, 2021, at 2 p.m., conducted with the DON, the DON stated the Patient Monitoring Graphic form was the only location in the patient record to document the patients' ADLs.

The DON stated hygiene and sleep should be documented every shift. The DON stated if the boxes were left blank, there was no indication the patients were assisted with the ADLs. The DON further stated there was no facility policy regarding the provision of ADLs.



43559

d. On September 30, 2021, Patient 15's record was reviewed. Patient 15 was admitted to the facility on July 25, 2021, with a diagnosis of paranoid schizophrenia. Patient 15 was discharged from the facility on August 12, 2021.

Patient 15's "Patient Monitoring Graphic Form," indicated a shower/bath was not documented on the following dates:

- July 26 to 31, 2021;

- August 1 to 7, 2021; and,

- August 10 to 12, 2021.

e. On October 1, 2021, Patient 16's record was reviewed. Patient 16 was admitted to the facility on August 27, 2021, with a diagnosis of major depressive disorder (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts.) Patient 16 was discharged from the facility on September 4, 2021.

Patient 16's "Patient Monitoring Graphic Form," indicated a shower/bath was not documented on the following dates:

- August 28, 2021; and,

- September 1, 2021.

Patient 16's "Daily Routine Vital Signs," documentation was missing on August 29, 2021, day shift, September 3, 2921, evening sift, and September 4, 2021, day shift.

f. On October 1, 2021, Patient 17's record was reviewed. Patient 17 was admitted to the facility on August 17, 2021, with a diagnosis of schizophrenia. Patient 17 was discharged from the facility on August 30, 2021.

Patient 17's "Patient Monitoring Graphic Form," indicated a shower/bath was not documented on the following dates:

- August 18 to 30, 2021.

g. On September 30, 2021, Patient 18's record was reviewed. Patient 18 was admitted to the facility on July 21, 2021, with the diagnosis of major depressive disorder. Patient 18 was discharged from the facility on July 28, 2021.

Patient 18's "Patient Monitoring Graphic Form," indicated a shower/bath was not documented on the following dates:

- July 22 to 25, 2021.

h. On September 30, 2021, Patient 19's record was reviewed. Patient 19 was admitted to the facility on September 13, 2021, with the diagnosis of Schizophrenia. Patient 19 was discharged from the facility on September 17, 2021.

Patient 19's "Patient Monitoring Graphic Form," indicated a shower/bath was not documented on the following dates:

- September 14, 2021; and,

- September 16 and 17, 2021.

i. On September 30, 2021, Patient 20's record was reviewed. Patient 20 was admitted to the facility on July 31, 2021, with the diagnosis of schizophrenia. Patient 20 was discharged from the facility on August 10, 2021.

Patient 20's "Patient Monitoring Graphic Form," indicated a shower/bath was not documented on the following dates:

- August 1 and 2, 2021; and,

- August 4 to 10, 2021.

j. On October 1, 2021, Patient 23's record was reviewed. Patient 23 was admitted to the facility on September 7, 2021, with a diagnosis of schizophrenia. Patient 23 was discharged from the facility on September 23, 2021.

Patient 23's "Patient Monitoring Graphic Form," indicated a shower/bath was not documented on the following dates:

- September 9 to 11, 2021; and,

- September 14 to 20, 2021; and,

- September 23, 2021.

k. On September 30, 2021, Patient 24's record was reviewed. Patient 24 was admitted to the facility on September 9, 2021, with a diagnosis of schizophrenia. Patient 24 was discharged from the facility on September 14, 2021.

Patient 24's "Patient Monitoring Graphic Form," indicated a shower/bath was not documented on the following date:

- September 11, 2021.

An interview was conducted with RN 1, on October 4, 2021, at 9:00 a.m. RN 1 stated the "Patient Monitoring Graphic Form," which included daily routine vital signs, meals, shift observations for contraband checks, and hygiene/sleep must be completed.

RN 1 stated the assigned nursing staff should document at least every shift reflecting the patient's condition and/or changes in patient's status.

RN 1 further stated there was no facility policy regarding the provision of ADLs.



39503

Based on interview and record review, the facility failed to ensure:

1. Adequate supervision of and evaluation of staff in MAB (Management of Assaultive Behavior) techniques, physical restraint takedowns, and the transfer of patients who were physically restrained on the floor were provided by the director of nursing services.

These failures resulted in the identification of immediate jeopardy related to unsafe use of physical restraints and unsafe transfer of patients who were physically restrained on the floor. These failures also had the potential to violate patient's rights and increase the risk for harm or death to the patients.

2. The laboratory tests were completed in accordance with the physician's orders, for one sampled patient (Patient 26).

This failure resulted in Patient 26's delay in treatment which may have an overall risk to the patient's safety and quality of care.

Findings:

1a. During an observation on September 28, 2021, at 3:30 p.m., in the facility lobby, Patient 12 was observed by two members of the survey team during a code white (indicating a pending emergency with a violent or combative patient) to be taken down to the ground, face down, and physically restrained by multiple staff members at each limb. Patient 12's right leg was observed to be physically restrained and held to the ground by Registered Nurse (RN) 3's left knee on the patient's right calf.

During an interview on September 28, 2021, at 3:40 p.m., conducted with RN 3, RN 3 stated he used his knee to physically restrain Patient 12's right leg after the patient was taken down to the ground. RN 3 stated this was a mistake. RN 3 stated knees should not be used to physically restrain patients and only hands should be used.

During an interview on September 29, 2021, at 10 a.m., conducted with the Director of Nursing (DON), the DON stated knees should never be used to physically restrain or contain patients. The DON stated only hands should be used when physical restraints were needed.

Patient 12's record was reviewed on October 1, 2021. Patient 12 was admitted to the facility on September 21, 2021, with diagnoses that included schizophrenia (a mental disorder) and autism (a developmental disability which could that cause significant social, communication, and behavioral challenges).

b. During an interview on September 28, 2021, at 1 p.m., conducted with RN 1, RN 1 stated when a patient was physically restrained on the floor, the correct way to transfer was by either escorting the patient onto his feet holding shoulder/arms or by using the gurney and flipping the patient over face up.

RN 1 stated he had seen patients at the facility being transferred face down by being lifted and carried by their limbs.

RN 1 stated it was very unsafe to transfer patients in this manner since it could cause hyperextension (the forceful extension of a limb or joint beyond its normal limits) and pain to the patient.

During an interview on September 28, 2021, at 4:20 p.m., conducted with Social Worker (SW) 1, SW 1 stated she was a witness to Patient 9's takedown to the ground and transfer from the floor to the restraint/seclusion room on September 27, 2021. SW 1 stated she witnessed Patient 9 transferred from the ground by four staff, one at each limb. SW 1 stated each staff member grabbed one of Patient 9's limbs, lifted the patient into the air, while the patient was face down, and carried him this way down the hallway, past the nurse's station, to the restraint/seclusion room. SW 1 further stated she verbalized to the staff they needed to stop because they were going to break his spine but the staff ignored her.

On September 29, 2021, Patient 9's record was reviewed. Patient 9 was admitted to the facility on September 21, 2021, with the diagnosis of schizophrenia.

Patient 9's "Seclusion/Restraint Packet," dated September 27, 2021, at 3 p.m., indicated the physician ordered mechanical and chemical restraints for Patient 9.

During an interview on October 1, 2021, at 9:10 a.m., with the DON, the DON stated there was no specific education or hands-on training provided to staff regarding the transfer patients who were physically restrained on the floor.

c. A review of Patient 1's record was conducted. Patient 1 was voluntarily admitted to the facility on September 20, 2021, with a diagnosis of schizoaffective disorder, bipolar type (a mental disorder characterized by abnormal thought processes, an unstable mood and episodes of mood swings).

An interview was conducted with RN 4, on September 27, 2021, at 3 p.m. RN 4 stated on September 23, 2021, around 3:30 p.m., a code white regarding Patient 1 was called. RN 4 further stated Patient 1 was cursing and threatening others.

During a concurrent observation and interview, on September 27, 2021, at 5 p.m. Patient 1 was observed seated in the facility's lobby. Patient 1 was alert, calm, his voice clear, as he stated he was discharged and waiting for transportation to take him home. Patient 1 stated, "I felt blows when I was being taken down, they put their knees on my neck. I said I couldn't breathe. They put me on a 72 hour hold (an involuntary hold when a patient was a danger to himself or others)."

Patient 1 further stated, "The social worker was very upset to see what happened to me. I was chicken winged (when a person was positioned on his stomach with the arms pulled to the back, elbows were up in the air, and the hands were behind the person's back) and they were (facility staff) were standing on the back of my feet. I have bumps on my head and my ribs hurt on my left side."

An interview was conducted with the Social Worker (SW) 1, on September 27, 2021, at 5:20 p.m. SW 1 stated she spoke with Patient 1 on September 24, 2021, and he told her he was "triggered by the floor staff (on September 23, 2021) and pushed the charge nurse and he knew it was his fault."

SW 1 stated she touched Patient 1's head and could feel bumps on top of his head. SW 1 stated Patient 1 told her the facility staff punched him on the back of his head and another staff twisted his arm behind his back and was kneeling on his back. SW 1 stated she observed red marks on his back and on the left side of his neck.

An interview was conducted with the Behavioral Health Associate (BHA) 1 on September 28, 2021, at 11 a.m. BHA 1 stated he was the target of Patient 1 when the patient became agitated last week on September 23, 2021. BHA 1 saw a staff member grab Patient 1's arm and put him to the ground.

BHA 1 further stated he had worked at the facility for nine months and before being hired, he had no prior training in mental health.

BHA 1 stated he had MAB (Management of Assaultive Behavior) training but did not have ongoing training in how to physically restrain a patient or how to place restraints on a patient.

BHA 1 stated he did not have an opportunity to practice hands-on techniques for restraining of patients. BHA 1 stated he would watch other staff to learn the takedown/restraint process.

BHA 1 stated he had put his knees on patient's arms or legs to restrain them and he had seen patients being picked up by their arms and legs while on their stomach.

An interview was conducted with the DON, on September 28, 2021, at 2 p.m. The DON stated during the process of restraining a patient, only a person's hands should be used to restrain a patient. The DON stated knees should never be placed on the patient's neck, back, or anywhere on the patient.

d. A review of Patient 3's record was conducted. Patient 3 was admitted to the facility on September 21, 2021, with a diagnosis of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).

An interview was conducted with the Marriage and Family Therapist (MFT) on September 27, 2021, at 12 p.m. The MFT stated she was present during a restraint episode involving Patient 3. She further stated during the restraint episode, she observed BHA 2 placing his knee on the Patient 3's neck and shoulder area.

An interview was conducted with BHA 2 on September 27, 2021, at 1:30 p.m. BHA 2 stated he participated in a restraint episode involving Patient 3 when the patient swung at him and was using vulgar language.

BHA 2 said he was able to take the patient down to the floor. BHA 2 stated BHA 1 and RN 4 came into the patient's room and transferred the patient to the bed by holding her arms and legs while in a prone position.

BHA 2 stated this was the first time he "took down" a patient and no one had taught him how to do that. BHA 2 stated he was not involved in the staff debriefing process after Patient 3's restraint episode.

An interview was conducted with BHA 1 on September 28, 2021, at 11:00 a.m. BHA 1 stated he was present during the restraint episode involving Patient 3 on September 23, 2021. BHA 1 stated he went to assist BHA 2 with Patient 3 as the patient was cursing and agitated.

BHA 1 stated he had worked at the facility for nine months and before being hired, he had no prior training in mental health.

BHA 1 stated he had MAB (Management of Assaultive Behavior) training but did not have ongoing training in how to physically restrain a patient or how to place restraints on a patient.

BHA 1 stated he did not have an opportunity to practice hands-on techniques for restraining of patients. BHA 1 stated he would watch other staff to learn the takedown/restraint process.

BHA 1 stated he had put his knees on patient's arms or legs to restrain them and he had seen patients being picked up by their arms and legs while on their stomach.

BHA 1 stated he helped other staff transfer Patient 3 to the bed. BHA 1 stated he grabbed Patient 3's arm and leg while she was lying on her stomach and assisted the staff in transferring the patient on the bed while she remained in a face down position.

An interview was conducted with the DON, on September 28, 2021, at 2 p.m. The DON stated during the process of restraining a patient only a person's hands and body weight should be used to restrain a patient. The DON stated knees or elbows should never be placed on the patient's neck, back, or anywhere on the patient. The DON stated during every restraint episode, a staff debriefing should be conducted to follow up on any problems encountered during the restraint process and all staff involved should be present at the debriefing. The DON stated the findings during the staff debriefing process would be used for education and training purposes.

An interview was conducted with the DON on September 29, 2021, at 9:20 a.m. The DON stated the BHAs were not utilizing the resources present in the facility to assist with patient transfers, such as using the backboards to safely transfer patients.

An interview was conducted with RN 1 on September 30, 2021, at 4 p.m., who stated prior to transferring a patient during a restraint episode, the patient must be rolled onto their back and placed onto a backboard or gurney to transfer the patient onto a bed. RN 1 further stated if a patient was transferred in a face down position the patient could hit their head on the floor.

During a review of the facility's policy and procedure titled, "Seclusion and Restraint of Patient," revised in September 2019, the P&P indicated, "...Staff Competency and Education...Employees must demonstrate competency in [MAB and Seclusion & Restraint] procedures...The focus of training is...containment techniques, including escort procedures..."



39503

2. During a concurrent interview and record review, on September 30, 2021, at 11 a.m., conducted with RN 1, Patient 26's record was reviewed. The "History and Physical," indicated Patient 26 was admitted to the facility on August 27, 2021, for psychiatric treatment.

The "Physician's Order," dated September 2, 2021, indicated Patient 26's clozapine (an antipsychotic medication) dose was to be increased to 125 milligram every 12 hours and for the patient to have a laboratory test for complete blood count (CBC, a blood test) every Tuesdays.

There was no documented evidence Patient 26's CBC blood draw every Tuesdays was done as ordered by the physician (a total of four CBC blood draw were missed since the physician ordered the test on September 2, 2021).

RN 1 stated when a patient was started on Clozapine medication, a CBC blood test would be ordered to monitor the patient's blood cells count.

RN 1 stated it was the facility's procedure when the physician ordered for the patient's laboratory test for the licensed nurse to write the order on the laboratory requisition paper and to file it in the laboratory binder. RN 1 stated the phlebotomist (a trained staff who would draw blood for the test) would come every morning, collect the requisition paper from the binder, and would draw the patient's blood for the laboratory test as indicated on the requisition paper.

RN 1 stated there was no evidence a requisition was completed for Patient 26's CBC blood test every Tuesday as ordered by the physician. RN 1 stated if there was no requisition made, then Patient 26's blood test would not be done.

According to Lexicomp Drugs, 2021, "...Clozapine...Alert...severe neutropenia (abnormally low count of a type of white blood cell [neutrophils, cells in the immune system that attacks bacteria and other organism in the body)...prior to initiating, obtain a baseline ANC (absolute neutrophil count [obtained on the CBC blood test])...to continue treatment, the ANC must be monitored regularly..."

During an interview on October 1, 2021, at 1 p.m., conducted with the DON, the DON stated the facility had no policy on laboratory orders and ensuring the test were completed. The DON stated the licensed nurses should follow the procedure of writing a laboratory requisition for the phlebotomist when the physician ordered for laboratory test on a patient.

Based on interview and record review, the facility failed to ensure:

1. For Patients 25, 28, 3, 4, 8, 9, 10, 14, 18, 21, and 23, the medications were administered as ordered by the physician.

In addition, the facility failed to ensure the physician was notified when Patient 25's Abilify (antipsychotic medication) was not available for medication administration.

These failures resulted into a medication administration errors and a delay in treatment of the patient's medical condition. These failures also had the potential to cause harm and/or deterioration of the patients' condition.

2. Assessment and reassessment were conducted when medications on as needed basis (PRN) were administered to Patients 28, 30, 6, 7, 8, 10, 13, and 14.

These failures had the potential to result in the patients' worsening condition to not be evaluated and managed, and for the patients' needs to not be addressed. In addition, these failures had the potential for delay in treatment for the patients which may cause harm and/or deterioration of the patients' condition.

3. For Patient 26, the physician was notified when the patient refused to take Synthroid (thyroid medication) and Depakote (medication used to treat seizure).

This failure resulted in a delay in treatment of the patient's medical condition and had the potential to cause harm and/or deterioration of the patients' condition.

Findings:

1a. During a concurrent interview and record review on September 30, 2021, at 10:40 a.m., conducted with Registered Nurse (RN) 1, Patient 25's record was reviewed. The "History and Physical" indicated Patient 25 was admitted to the facility on July 5, 2021, for psychiatric treatment.

The "Physician's Order," dated August 20, 2021, indicated for Patient 25 to receive Abilify 400 milligram (mg) intramuscularly (IM, injection to the muscle) once on August 23, 2021.

Patient 25's "Medication Administration Record (MAR)," dated August 23, 2021, did not indicate Abilify was administered to the patient;

RN 1 stated Abilify was a non-formulary medication (medications not approved by the insurance) and was not available at the facility. RN 1 stated the pharmacy who reviewed the order should have informed the physician of the unavailability of the medication. RN 1 stated Patient 25's RN should have informed the physician of this as well for unavailability of Abilify.

RN 1 stated there was no documented evidence the physician was notified when Abilify was not administered to Patient 25 on August 23, 2021, due to the unavailability of the medication.

Patient 25's MAR, dated August 27, 2021, indicated the following:

- Ativan (medication for anxiety) 1 mg, give one tablet by mouth every 12 hours, due at 9 a.m., and 9 p.m.

There was no documented evidence the 9 p.m. dose of Ativan was administered to the patient;

- Lipitor (medication used for treatment of high cholesterol) 20 mg, give one tablet by mouth at night, due at 9 p.m.

There was no documented evidence the 9 p.m. dose of Lipitor was administered to the patient; and,

- Haldol (antipsychotic medication) 5 mg, give one tablet by mouth in the morning and at night, due at 9 a.m., and 9 p.m.

There was no documented evidence the 9 p.m. dose of Haldol was administered to the patient.

Patient 25's MAR, dated September 13, 2021, indicated the following:

- Lipitor 20 mg, give one tablet by mouth at night, due at 9 p.m.

There was no documented evidence the 9 p.m. dose of Lipitor was administered to the patient;

- Haldol 5 mg, give one tablet by mouth at night, due at 9 p.m.

There was no documented evidence the 9 p.m. dose of Haldol was administered to the patient; and,

- Zyrtec (medication for allergy) 10 mg, give one tablet by mouth at night, due at 9 p.m.

There was no documented evidence the 9 p.m. dose of Zyrtec was administered to the patient.

Patient 25's MAR, dated September 28, 2021, indicated the following:

- Glucophage (medication for treatment of high blood sugar level) 500 mg, give one tablet by mouth twice a day, due at 9 a.m., and 5 p.m.

There was no documented evidence the 9 a.m. and 5 p.m. doses of Glucophage were administered to the patient;

- Give Haldol 5 mg one tablet by mouth in the morning, due at 9 a.m.

There was no documented evidence the 9 a.m. dose of Haldol was administered to the patient; and,

- Nicotine patch (used to help in smoking cessation) 7 mg, apply one patch to skin every day for seven days, due at 9 a.m.

There was no documented evidence the 9 a.m. dose of the nicotine patch was administered to the patient.

RN 1 stated when medication was administered to the patient, the licensed nurse should initial on the time the medication was due to indicate it was administered to the patient.

RN 1 stated when the medication was not given to the patient as scheduled, the licensed nurse should document on the MAR by circling the time the medication was due and the RN should document the reason for the medication not given.

RN 1 stated there was no documentation the medications were administered to Patient 25 on the dates and times mentioned above.

RN 1 stated there was no documentation as to why the medications were not administered as scheduled.

b. During a concurrent interview and record review on October 1, 2021, at 11 a.m., with the Director of Nursing (DON), Patient 28's record was reviewed. The "History and Physical" indicated Patient 28 was admitted to the facility on August 9, 2021, for medication overdose.

Patient 28's "Medication Administration Record (MAR)," dated August 14, 2021, indicated the following:

- Neurontin (pain medication) 100 mg (milligrams), give two capsules by mouth four times a day, due at 9 a.m., 1 p.m., 5 p.m., and 9 p.m.

There was no documented evidence the 5 p.m., and 9 p.m., doses had were administered to the patient; and

- Flomax (medication for treatment of enlarge prostate) 0.4 mg, give one capsule at night, due at 9 p.m.

There was no documented evidence the 9 p.m. dose was administered to the patient.

The DON stated when a medication was administered to the patient, the licensed nurse should initial on the time the medication was due to indicate it was administered to the patient.

The DON stated there was no documentation the medications were administered to Patient 25 on the dates and times mentioned above.

The DON stated there was no documentation as to why the medications were not administered as scheduled.



22384

c. A review of Patient 3's record was conducted on September 30, 2021. Patient 3 was admitted to the facility on September 21, 2021, with a diagnosis of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Patient 3 was discharged on September 29, 2021.

A review of Patient 3's medication history indicated the patient's home medications included Lithium 300 mg every evening (a mood stabilizer used to treat or control the manic episodes of bipolar disorder).

A review of the MAR for Patient 3 was conducted with the DON, on September 30, 2021, at 10 a.m. The MAR reflected on September 25, 2021, Patient 3 was prescribed Lithium 300 mg every 12 hours for her bipolar diagnosis, to be administered at 9 a.m. and 9 p.m.

The record reflected Patient 3 was discharged on September 29, 2021, and did not receive her 9 a.m., dose of Lithium.

A concurrent interview was conducted with the DON who stated the patient was discharged at 11:10 a.m., and should have received her 9 a.m. dose of Lithium prior to discharge.

d. A review of Patient 4's record was conducted. Patient 4 was admitted to the facility on September 1, 2021, with a diagnosis of schizophrenia (a mental disorder).

A review of Patient 4's MAR indicated a physician's order was documented on September 2, 2021, for Patient 4 to have Ashlyna (medication for birth control) one tablet orally every evening. The physician further indicated, "May take own supply/ (name of family member) to bring."

The record failed to show Patient 4 received Ashlyna every evening as ordered by the physician.

An interview was conducted with RN 1, on September 30, 2021, at 2:30 p.m. RN 1 stated when a home medication would be used in the facility, the pharmacist or the physician should verify prior to use. RN 1 further stated the facility document titled, "Patients Own Medication Form," must be filled out. RN 1 stated there was no documentation the form was completed.

RN 1 stated after reviewing Patient 4's record, the Ashlyna prescription "dropped off" the MAR on September 9, 2021, and the medication was not documented as having being given to Patient 4 prior to that time or after.

A review of the facility policy and procedure titled, "Medication Brought In With Patients," dated July 2020, indicated, "...To ensure that medications brought in by the patient are utilized during their stay, disposed of properly or stored properly in a manner consistent with State and Federal law, Joint Commission Standards, and professional practice...When the pharmacist is on duty, for those medications that will be used by the patient during their admission at the facility, the medications will be inspected for proper identification, labeling, and visual evaluation as part of the pharmacist verification process..If the pharmacist is not on duty, the physician will be asked to verify the drug..."



42082

e. On September 28, 2021, Patient 8's record was reviewed. Patient 8 was admitted to the facility on April 17, 2021, with diagnoses including depression and diabetes (a chronic disease associated with abnormal levels of sugar in the blood).

The physician's telephone orders, dated April 18, 2021, at 2:21 a.m., indicated, "...Start Accu-check (monitoring of blood sugar)...Insulin (medication to regulate blood sugar) sliding scale (doses administered based on blood sugar level)..."

The "Routine Medication Record," dated April 18, 2021, through April 20, 2021, indicated, "...Blood glucose (sugar) checks AC (before meals) tid (three times a day) Humalog (type of insulin) sliding scale..."

During a concurrent interview and record review, on September 29, 2021, at 10:30 a.m., conducted with the DON, Patient 8's MAR, dated April 19, 2021, was reviewed. The MAR indicated, for the 11 a.m,. and 4 p.m., scheduled administration times, the boxes were blank and there were no licensed nurse initials.

The DON stated there was no documentation indicating Patient 8's blood sugar was checked, or insulin was given, on April 19, 2021, for the 11 a.m. and 4 p.m. scheduled administrations.

f. On September 29, 2021, Patient 9's record was reviewed. Patient 9 was admitted to the facility on September 21, 2021, with a diagnosis of schizophrenia.

The physician's telephone order, dated September 23, 2021, at 5:04 p.m., indicated to apply triple antibiotic ointment twice a day to left eye abrasion for five days.

During a concurrent interview and record review on September 29, 2021, at 2 p.m., conducted with the DON, Patient 9's MAR, dated September 23, 2021, through September 29, 2021, was reviewed. The MAR indicated there were no licensed nursing staff initials in the box for Patient 9's antibiotic ointment on September 24, 27, and 28, 2021, at 5 p.m.

The DON stated there was no documentation indicating wound care was performed and antibiotic ointment was applied on Patient 9 for the above scheduled administrations.

g. On September 30, 2021, Patient 10's record was reviewed. Patient 10 was admitted to the facility on April 29, 2021, with diagnoses that included bipolar disorder and hypertension (high blood pressure).

The physician's order, dated May 9, 2021, at 7:50 p.m., indicated, "Neosporin ointment (an antibacterial medication used to prevent infection) topically (application to body surface, such as skin) to hands qid (four times a day) starting at 9:00 p.m. for 5 (five) days..."

During a concurrent interview and record review, on September 30, 2021, at 9:15 a.m., conducted with the DON, Patient 10's MAR, dated May 8, 2021, through May 10, 2021, was reviewed. The MAR indicated, on May 9 and 10, 2021, there were no times or licensed nurse initials in the boxes indicating Neosporin was administered to Patient 10.

The DON stated there was no documentation on the MAR indicating Patient 10 received Neosporin at any time on May 9 or 10, 2021.

h. On October 1, 2021, Patient 14's record was reviewed. Patient 14 was admitted to the facility on September 23, 2021, with diagnoses that included schizophrenia and elevated blood pressure (BP).

The physician's telephone order, dated September 23, 2021, at 3:08 p.m., indicated to administer Clonidine 0.1 mg by mouth every 12 hours as needed for elevated BP greater than or equal to 160/100.

During a concurrent interview and record review on October 1, 2021, at 3:15 p.m., conducted with the DON, Patient 14's BP readings for the following dates and times were:

- On September 24, 2021, at 5 p.m., the BP was 175/101;

- On September 25, 2021, at 6 a.m., the BP was 165/85;

- On September 26, 2021, at 5 p.m., the BP was 183/114; and,

- On September 28, 2021, at 6 a.m., the BP was 181/104.

The DON reviewed Patient 14's record and stated there was no documentation indicating Patient 14 was administered Clonidine as ordered by the physician for the elevated BPs.

i. On September 30, 2021, Patient 18's record was reviewed. Patient 18 was admitted to the facility on July 2, 2021, with the diagnosis of depression.

Patient 18's physician's telephone order, dated July 21, 2021, at 1:04 p.m., indicated:

- Lisinopril (medication for hypertension)10 mg by mouth every morning;

- Nicotine Patch 14 mg apply one patch daily; and,

- Depakote 500 mg by mouth every night.

A concurrent interview and record review on September 30, 2021, at 11:25 a.m., was conducted with RN 1. RN 1 stated the MAR indicated the following medications were not administered to Patient 18 on July 24 and 25, 2021:

- Lisinopril 10 mg;

- Nicotine Patch 14 mg; and,

- Depakote 500 mg.

j. On October 1, 2021, Patient 21's record was reviewed. Patient 21 was admitted to the facility on September 8, 2021, with the diagnosis of schizophrenia.

Patient 21's physician's telephone order, dated September 8, 2021, at 8:45 p.m., indicated to administer Clonidine 0.1 mg (milligrams) by mouth every 12 hours as needed for elevated BP of greater than or equal to 160/100.

During a concurrent interview and record review on October 1, 2021, at 3:15 p.m., conducted with the DON, Patient 14's BP readings were reviewed for the following dates and times:

- On September 9, 2021, at 5 p.m., the BP was 161/107;

- On September 10, 2021, at 6 a.m., the BP was 161/98; and,

- On September 10, 2021, at 5 p.m., the BP was 165/102.

The DON stated there was no documentation Patient 21 received Clonidine as ordered by the physician for the elevated BPs.

k. On October 1, 2021, Patient 23's record was reviewed. Patient 23 was admitted to the facility on September 7, 2021, with the diagnosis of schizophrenia.

Patient 23's physician's telephone order, dated September 13, 2021, at 8:17 p.m., indicated, " ...Haldol 10 mg, Ativan 2 mg, and Benadryl 50 mg, IM X 1 STAT (immediately), for masturbating in public and exposing self to female peers.

There was no documented evidence Haldol, Ativan, and Benadryl were administered to Patient 23 on September 13, 2021.

During a concurrent interview and record review on October 4, 2021, at 10:20 a.m., conducted with Registered Nurse (RN) 1, Patient 23's MAR was reviewed. RN 1 stated there was no documentation the Haldol, Ativan, and Benadryl was administered to Patient 23 on September 13, 2021.

RN 1 stated all administered medications should be documented with date, time, and nurse's initials on the MAR.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration and Records," reviewed in July 2020, the P&P indicated, "...At the designated times, the nurse will administer all medications to patients...To indicate the administration of a scheduled medication, the nurse will cross out the time the medication was administered and initial directly to the right of the medication with time...If a scheduled medication is refused or not given, then the medication time is circled; and the nurse's initials are written directly to the right of the refused time. In addition, the nurse will place the appropriate note in the chart..."

2a. During a concurrent interview and record review on October 1, 2021, at 11 a.m., with the DON, Patient 28's record was reviewed. The "History and Physical" indicated Patient 28 was admitted to the facility on August 9, 2021, for medication overdose.

Patient 28's MAR, dated August 13, 2021, indicated a physician's order of Clonidine 0.1 mg, to give one tablet by mouth every 12 hours as PRN for BP higher than 160/100 mmHg (millimeter of mercury, unit of measurement) to be repeated every two hours until the patient's BP was within the paramenters and to call the physician if the BP remained elevated after four hours.

Further review of the MAR indicated Patient 28 was given Clonidine dose at 6:30 a.m., for a BP of 181/81.

There was no documented evidence Patient 28's BP was reassessed two hours after the Clonidine was given.

The DON stated when the patient was given PRN medication, the nurse should reassess the patient to know if the medication given was effective or further intervention was needed.

The DON stated Patient 28's BP was high and should have been reassessed after the Clonidine was given.

Patient 28's MAR, dated August 13, 2021, indicated a physician's order of Tylenol (pain medication) 325 mg, to give two tablet by mouth every four hours PRN for pain.

Further review of the MAR indicated Patient 28 was given Tylenol at 8:23 a.m.

There was no documented evidence Patient 28's pain was assessed before and after the pain medication was given.

The DON stated when the patient was given PRN medication, the nurse should reassess the patient to know if the medication given was effective or further intervention was needed.

The DON stated Patient 28's pain should have been assessed before and after the Tylenol was given.

b. During a concurrent interview and record review, on October 1, 2021, at 12:15 p.m., with the Director of Nursing (DON), Patient 30's record was reviewed. The "History and Physical" indicated Patient 30 was admitted to the facility on September 21, 2021, for psychiatric treatment.

Patient 30's MAR indicated a physician's order of Tylenol (pain medication) 325 mg, to give two tablet by mouth every four hours PRN for pain.

Further review of the MAR indicated Patient 30 was given Tylenol on the following dates and times:

- On September 24, 2021, at 3:04 a.m.;

- On September 25, 2021, at 6:37 a.m.;

- On September 26, 2021, at 2:30 p.m., and 6:30 p.m.; and,

- On September 27, 2021, at 10:30 a.m., and 2:30 p.m.

There was no documented evidence Patient 30's pain was assessed before and after the pain medication was given on the dates and times mentioned above.

The DON stated when the patient was given PRN medication, the nurse should reassess the patient to know if the medication given was effective or further intervention was needed.

c. A review of Patient 6's record was conducted. Patient 6 was admitted to the facility on September 16, 2021, with a diagnosis of schizoaffective disorder, bipolar type (a combination of symptoms of schizophrenia and mood disorder), and chronic pain syndrome. The patient had an extensive history of polysubstance abuse.

A review of Patient 6's MAR, indicated the following:

- On September 18, 2021, at 12:19 p.m., Motrin (an anti-inflammatory medication for pain relief), one tablet, 600 milligrams (mg) prn, for moderate pain, was administered to Patient 6.

The record failed to show Patient 6's pain was assessed before and after the medication was given;

- On September 18, 2021, at 6 p.m., Flexeril (a muscle relaxant which could treat pain), one tablet prn 10 mg was administered to Patient 6.

The record failed to show the degree of Patient 6's pain was assessed before and after the medication was given;

- On September 19, 2021, at 4:40 p.m., Ativan 2 mg orally prn was administered to Patient 6.

The record failed to show why the medication was administered, or if it relieved the patient's symptoms;

- On September 20, 2021, at 8:10 a.m., Ativan 2 mg orally prn was administered to Patient 6.

The record failed to show why the medication was administered, or if it relieved the patient's symptoms;

- On September 28, 2021, at 7:49 a.m., Flexeril one tablet orally, 10 mg prn, was administered to Patient 6.

The record failed to show the degree of Patient 6's pain was assessed before and after the medication was given; and,

- On September 28, 2021, at 12:40 p.m., Zofran (medication for nausea and vomiting), one tablet orally, 4 mg prn was administered to Patient 6.

The record failed to show why the medication was administered or if it relieved the patient's symptoms.

An interview was conducted with RN 2, on October 1, 2021, at 11:30 a.m. RN 2 stated prior to, and after administering prn medications to patients, the reason for giving the medication, the pain score as appropriate, and if the medication relieved the problem/symptom must be documented.

d. A review of Patient 7's record was conducted. Patient 7 was admitted to the facility on September 24, 2021, with a diagnosis of chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing).

A review of the MAR for Patient 7 reflected the Albuterol Nebulizer (used to treat bronchospasms), was ordered every four hours prn for asthma (condition in which a person's airways became inflamed, narrow and swollen making it difficult to breathe)/ COPD symptoms.

The Albuterol Nebulizer was administered to Patient 7 on the following dates and times:

- On September 25, 2021, at 6 a.m..;

- On September 26, 2021, at 5:35 p.m.; and,

- On September 28, 2021, at 9 a.m.

The record failed to show the reasons for administering the medication, and if the medication was effective.

e. A review of the MAR for Patient 7 reflected the Tylenol 650 milligrams (mg) was ordered for Patient 7 to be given orally every 4 hours as needed for pain.

The Tylenol 650 mg was administered to Patient 7 on September 25, 2021, at 2:40 p.m.

The record failed to show where the patient's pain was located, what the degree of the pain was, and if the patient's pain was relieved.

An interview was conducted with RN 2, on October 1, 2021, at 11:30 a.m. RN 2 stated prior to, and after administering prn medications to patients, the reason for giving the medication must be documented, the pain score documented as appropriate, and if the medication relieved the problem/symptom.

f. On September 28, 2021, Patient 8's record was reviewed. Patient 8 was admitted to the facility on April 17, 2021, with diagnoses that included depression.

The physician's telephone order, dated April 17, 2021, at 7:19 p.m., indicated, "...Tylenol 650 mg PO (by mouth) Q4hrs (every four hours) - PRN - Mild-Moderate Pain..."

During a concurrent interview and record review, on September 29, 2021, at 10:30 a.m., conducted with the DON, Patient 8's MAR, dated April 18, 2021, through April 19, 2021, was reviewed.

The MAR indicated, on April 19, 2021, at 8:45 p.m., Patient 8 was administered Tylenol for pain.

There was no documented evidence Patient 8's pain was assessed before or after the Tylenol was administered.

The DON stated a pain assessment should be performed before and after all prn pain medications to determine whether the medication was effective.

The DON stated there was no documentation indicating Patient 8's pain was assessed for the administration of Tylenol on April 19, 2021, at 8:45 p.m.

g. Patient 8's physician telephone order, dated April 17, 2021, at 7:19 p.m., indicated to administer Clonidine 0.1 mg by mouth every 12 hours as needed for elevated BP greater than or equal to 160/100; Record BP upon initial dose and every two hours until BP within parameters, and call physician if BP remains elevated after four hours.

During a concurrent interview and record review, on September 29, 2021, at 10:30 a.m., conducted with the DON, Patient 8's MAR, dated April 19, 2021, was reviewed. The MAR indicated, on April 19, 2021, at 6:45 a.m., Patient 8 was administered Clonidine for a BP of 157/109.

There was no documentation that indicated a repeat BP was done after the clonidine was administered.

The DON stated an assessment for all prn medications should be done after being administered to determine whether medication was effective.

The DON stated there was no documentation that indicated Patient 8's BP was rechecked every two hours as per the physician's order after the Clonidine was administered.

h. On September 30, 2021, Patient 10's record was reviewed. Patient 10 was admitted to the facility on April 29, 2021, with diagnoses that included bipolar disorder and hypertension.

The physician's telephone order, dated April 29, 2021, at 8:30 a.m., indicated to administer Clonidine 0.1 mg by mouth every 12 hours as needed for elevated BP greater than or equal to 160/100, to record Patient 10's BP upon initial dose and every two hours until the BP was within parameters, and to call the physician if the BP remained elevated after four hours.

During a concurrent interview and record review, on September 29, 2021, at 10:30 a.m., conducted with the DON, Patient 8's MAR, dated May 1, 2021, through May 3, 2021, was reviewed.

The MAR indicated, on May 2, 2021, at 9 a.m., Patient 10 was administered Clonidine for a BP of 139/113.

There was no documentation that indicated a repeat BP was done after the Clonidine was administered.

The DON stated an assessment for all prn medications should be done after being administered to determine whether medication was effective.

The DON stated there was no documentation indicating the BP was rechecked for Patient 10 every two hours as per the physician's order after the Clonidine was administered.

i. On October 1, 2021, Patient 13's record was reviewed. Patient 13 was admitted to the facility on September 28, 2021, with the diagnosis of schizophrenia.

The physician's telephone order, dated September 28, 2021, at 3:14 p.m., indicated to administer Clonidine 0.1 mg by mouth every 12 hours as needed for elevated BP greater than or equal to 160/100, to record Patient 13's BP upon initial dose and every two hours until BP within parameters, and to call the physician if the BP remained elevated after four hours.

During a concurrent interview and record review, on October 1, 2021, at 3:15 p.m., conducted with the DON, Patient 13's MAR, dated September 29, 2021, was reviewed. The MAR indicated, on September 29, 2021, at 6:50 p.m., Patient 13 was administered Clonidine for a BP of 165/113.

There was no documentation that indicated a repeat BP was done after the clonidine was administered.

The DON stated an assessment for all prn medications should be done after being administered to determine whether medication was effective.

The DON stated there was no documentation indicating Patient 13's BP was rechecked every two hours as per the physician's order after the Clonidine was administered.

j. On October 1, 2021, Patient 14's record was reviewed. Patient 14 was admitted to the facility on September 23, 2021, with diagnoses that included schizophrenia and elevated BP.

The physician's telephone order, dated September 23, 2021, at 3:08 p.m., indicated to administer to administer Clonidine 0.1 mg by mouth every 12 hours as needed for elevated BP greater than or equal to 160/100, to record Patiemt 14's BP upon initial dose and every two hours until the BP was within parameters, and to call the physician if the BP remained elevated after four hours.

Further review of Patient 14's MAR, dated September 25, 2021, through September 29, 2021, indicated Patient 14 was administered Clonidine on the following dates and times:

- On September 25, 2021, at 7:05 p.m., for a BP of 169/104; and

- On September 29, 2021, at 6:50 p.m., for a BP of 161/88.

There was no documentation indicating rechecking of the BPs were done for Patient 14 after the above administrations of Clonidine.

The DON stated an assessment for all prn medications should be done after being administered to determine whether the medication was effective.

The DON stated there was no documentation indicating repeat BPs were taken for Patient 14 every two hours as per the physician's order after the administrations of Clonidine as mentioned above.

During a review of the facility's P&P titled, "Medication Administration and Records," reviewed in July 2020, the P&P indicated, "...Documentation of a patient's response to PRN medications must be documented..."

During a review of the facility's P&P titled, "Pain Assessment and Management," reviewed in January 2021, the P&P indicated, "...Whenever the patient reporting pain requires PRN medication for pain, the nurse will assess with the patient's pain using a numerical scale. This assessment will be documented on the Pain and PRN Medication Administration Record. Reassessment of pain is performed, using the numerical scale, when the pharmacological intervention has reached its peak, generally within 30 - 60 minutes. This reassessment will also be documented..."



43559

3. During a concurrent interview and record review, on September 30, 2021, at 11 a.m., conducted with RN 1, Patient 26's record was reviewed. The "History and Physical" indicated Patient 26 was admitted to the facility on August 27, 2021, for psychiatric treatment.

Further review of the record indicated Patient 26 had a medical history of schizophrenia and hypothyroidism (deficiency of thyroid hormones).

a. Patient 26's MAR indicated a physician's order of Synthroid 100 microgram (mcg), give one tablet by mouth in the morning, due at 6:30 a.m.

The MAR indicated the scheduled time for Synthroid was circled and had an initial of the licensed nurse on September 2 to 3, 9 to 10, 18 to 20, and 23 to 28, 2021

RN 2 stated when a medication was not given or refused by the patient, the nurse would circle the scheduled time of the medication and will have the nurse's initials.

RN 2 stated when a medication was not given or refused by the patient, the nurse should notify the physician to receive further instructions from the physician.

RN 2 stated Patient 26 did not receive Synthroid on the dates mentioned above. RN 2 stated there was no documentation the physician was notified Synthroid was not administered to Patient 26 on September 2, 3, 9, 10, 18, 19, 20, and 23 to 28, 2021.

b. Patient 26's MAR indicated a physician's order of Depakote 500 mg, to give two tablet by mouth twice a day, due at 9 a.m., and 9 p.m.

The MAR indicated the scheduled time for Depakote was circled and had an initial of the licensed nurse on the following dates and times:

- September 18 and 19, 2021, at 9 a.m.;

- September 20, 2021, at 9 p.m.;

- September 23, 2021, at 9 a.m. and 9 p.m.;

- September 24, 2021, at 9 p.m.; and,

- September 25, 26, 27, and 29, 2021, at 9 a.m. and 9 p.m.

RN 1 stated when a medication was not given or refused by the patient, the nurse would circle the scheduled time of the medication and will have the nurse's initials.

RN 1 stated when a medication was not given or refused by the patient, the nurse should notify the physician to received further instructions from the physician.

RN 1 stated the documentation indicated Patient 26 refused to take Depakote on the dates and times mentioned above. RN 1 stated there was no documentation the physician was notified of Patient 26's refusal to take Depakote.

During a review of the facility's P&P titled, "Medication Administration and Records," dated July 2020, the P&P indicated, "...If a scheduled medication is refused or not given, then the medication time is circled; and the nurse's initials are written directly to the right of the refused time. In addition, the nurse will place the appropriate note in the chart..."